Pediatric Plastic and Reconstructive Surgery

Fig. 23.6 Diagramatic representation of a
“babysitter” procedure in which the main trunk
of the injured right facial nerve (DISTAL to the
site of injury) is turned down and anastamosed
end-to-side to the hypoglossal nerve temporarily
neurotise the injured facial nerve and keep the
motor end plates of the facial muscles intact until
such time as axons from a cross facial nerve graft
can reach the injured nerve. The arrows represent
the direction of growth of the neurones.
Table 23.1 Summary of the various reconstructive procedures that may be used in facial reanimation
Static procedures

Dynamic procedures
Brow

Direct excision brow lift
Open brow lift
Endoscopic brow lift
Contralateral weakening
Upper eye lid

Weights

Palpebral springs
Tarsorrhaphy

Temporalis transfer
Levator botulinum toxin

Direct muscle neurotization
Cross facial transfer
Free muscle transfer
Lower lid

Static sling

Temporalis transfer
Lateral canthoplasty

Direct muscle neurotization
Medical canthoplasty

Cross-facial transfer
Lid shortening

Free muscle transfer
Nasal airway

Cheek lateralization procedures
Tendon sling
Septoplasty
Commissure/upper lip

Static slings

Direct muscle neurotization
Direct muscle
Cross facial transfer
Regional muscle transfer
Free muscle transfer
Soft-Tissue Deformities of the Head and Neck
234

smaller, lower profile platinum plates, and related techniques
such as the use of magnetized and silicone-implantable devices,
although these are less common.
Other static procedures that are more rarely used in the
pediatric population include the use of a palpebral spring sys-
tem (Fig. 23.8) and tarsorrhaphy. The principle of tarsorrha-
phy is to fuse the upper and lower eyelids by one of several
di erent methods, reducing excursion and narrowing the pal-
pebral aperture. A tarsorrhaphy is relatively simple and may be
permanent, or where recovery or another definitive eyelid pro-
cedure is expected, temporary.
Of the dynamic procedures, a strip of temporalis muscle is
dissected and transposed anteriorly, extended by means of
fascial or tendon grafts, and attached to the upper and lower
eyelids, allowing voluntary (but not reflex) movement, con-
trolled by temporalis contraction (Fig. 23.9). More recently,
dynamic “spontaneous and symmetrical” procedures have been
developed, such as a free platysma transfer powered by a cross-
facial nerve graft.
The use of botulinum toxin for the levator palpebrae supe-
rioris to counter the e ect of the orbicularis may also be
used as a temporary measure in order to allow corneal
ulcers to heal.
Generally, contralateral balancing procedures are not
appropriate for the upper eyelid as they would risk causing
lid ptosis.
Fig. 23.7 A diagram showing the use of gold
weights for the management of upper lid–related
lagophthalmos. The weight is placed just anterior
to the tarsal plate through an “upper-blephar-
oplasty” type incision.
Fig. 23.8 A schematic demonstrating the spring
technique by Morel-Fatio and Lalardie (1964). The
spring (blue) is placed in the lateral canthal
region. One arm of the spring pushes against the
orbital roof and the other against the lower lid,
enabling it to close.
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235

23.7.3 The Lower Eyelid
The lower eyelid is also not commonly a problem in children.
While like the upper eyelid the problem is one impairing
closure of the eyelid, the etiology and e ect of the problem are
somewhat di erent. In the upper eyelid, the problem is one of
unopposed levator action and inadequate motion, but in the
lower eyelid, the “antagonist” is gravity and the problem is of
inadequate support. It may be that the relative resilience of the
pediatric population to lower lid problems is associated with
their greater soft-tissue elasticity. The problem with lower lid
paralysis is the potential for ectropion. The result is that due to
the increased exposure of the eye, there is a feeling of dryness
and also a paradoxical simultaneous epiphora, resulting from
the loss of opposition of the lower lid lacrimal punctum to the
globe of the eye.
In the event of lower lid ectropion, many of the dynamic pro-
cedures that can be used are similar to those for the upper lid—
the temporalis transfer, cross-face neurotization procedures,
and free tissue transfer. In our experience, though, static proce-
dures—which essentially act to lend support to the drooping
lower lid—are usually adequate. A tendon graft may be passed
through the lower lid between the canthi and tightened to
form a static sling helping appose the lower lid to the globe
(Fig. 23.10). Medial and lateral canthoplasties may also be
performed. In the event of the primary problem being an exces-
sively everted lacrimal punctum within the lower lid, a tarso-
conjunctival ellipse may be excised from the medial lower lid to
reposition the medial canthus. If the problem is primarily lat-
eral, a lateral canthoplasty by a canthopexy or tarsal strip pro-
cedure may be performed, in which the lateral canthus is
resuspended from the orbital rim.
23.7.4 The Nasal Airway
As a result of loss of ipsilateral soft-tissue support of the nose,
the nasal airway may be prone to collapse. In unilateral cases,
there is enough redundancy that the contralateral nasal airway
is adequate to allow comfortable respiration, though if severe
Fig. 23.9 Diagram adapted from Kazenstein describing the use of the
temporalis transfer technique (1916). A segment of the temporalis
muscle is turned down, split, and transferred to the eyelids and oral
commissure.
Fig. 23.10 (a) Incisions are located at A, B, and C. (b) The sling is positioned over the tarsal plate with a lacrimal probe in place to prevent damage to
canaliculus. (c) A strip of tendon is passed through the eye of a Keith needle. (Adapted from Carraway and Manktelow 1999.)
Soft-Tissue Deformities of the Head and Neck
236

and bilateral it may be addressed with suspension procedures.
Occasionally, if associated with septal deviation, it may benefit
from septoplasty. However, in general, problems around nasal
collapse are often addressed by secondary benefit of procedures
that act to suspend the upper lip and oral commissure and so
indirectly act on the nasal airway.
23.7.5 The Upper Lip and Oral
Commissure
Within the pediatric population, the loss of midface symmetry
and the “smile” is the most common reason for presentation,
and the most common indication for surgical intervention. It is
primarily as a result of the loss of function of the lateral and
superior pull of the zygomaticus major and minor (“the Mona
Lisa smile”), and levator labii superioris (“the canine smile;”
Fig. 23.11). Over the years, many static and dynamic proce-
dures have been developed to manage this problem. Static
suspension of the upper lip and the commissure by means of
tendon and fascia grafts and alloplastic materials such as
Gore-Tex is a well-described option (Fig. 23.12). For dynamic
reconstruction, cross-facial nerve grafting may be done to
residual distal nerve stumps where present, or as with the orbi-
cularis oris for eyelid problems direct neurotization from the
contralateral facial nerve is also an option.
Where no usable muscle is present, a muscle transfer is
required. Local options include the use of the masseter, and per-
haps one of the most well-known local options is the use of a
temporalis transfer ( Fig. 23.13). In this technique, the tempo-
ralis muscle is mobilized from the posterior part of its origin in
the temporal fossa and its insertion in the coronoid process is
redirected under the zygomatic arch to the oral commissure.
Our preferred technique is the use of a two-stage procedure—
a cross-facial nerve transfer followed by a free gracilis transfer.
In the first stage, a cross-face nerve graft is performed. Given
that it is possible to use other local nerves to power the muscle
transfer rather than a cross-face nerve graft, it is the authors’
opinion that the great merit of a muscle powered by the facial
nerve (albeit the contralateral facial nerve) is that it allows a
truly emotionally spontaneous and bilaterally synchronous
movement. The operation is performed as a two-team
approach. The sural nerve is identified under tourniquet control
at three locations by means of three short incisions just poste-
rior to the lateral malleolus, in the midcalf and in the popliteal
fossa. A specially designed nerve stripper is then used to deli-
cately harvest the nerve, which is reversed prior to grafting.
Simultaneously, the una ected side of the face is exposed via a
“face-lift” type incision, and the facial nerve is identified. The
required branches are those that stimulate the desired “smile”
on the una ected side. These are then sharply divided (there is
invariably adequate redundancy and crossover, so the nonpara-
lyzed side’s function is not impaired). The sural nerve graft is
then either sutured or glued to these branches and tunneled to
the contralateral side. The patient is then regularly assessed
using Tinel’s sign, and after a period of 4 to 6 months once the
cross-face nerve graft has neurotized to the a ected side, the
second stage—the free gracilis transfer—may be performed.
In some cases, however, a cross-face nerve graft is not possi-
ble, for example, when there is a bilateral facial paralysis, and in
this case the authors’ second choice is a single-stage procedure
in which the gracilis is innervated by the ipsilateral nerve to
masseter. The gracilis is a type 2 Mathes and Nahai muscle flap
(Fig. 23.14), the dominant pedicle being from a branch of the
profunda femoris. It is innervated by the anterior obturator
nerve and its harvest causes minimal donor site morbidity. The
original description by Harii of the flap was of the whole gracilis
muscle, but the result was a bulky flap. This has subsequently
been refined so that now it is only necessary to use a small lim-
ited segment of the muscle, using nerve stimulation to identify
Fig. 23.11 Diagrammatic representation of the
levator labii superioris and the zygomaticus
muscles’ action and giving their vector of pull on
the oral commissure.
Facial Paralysis
237

Fig. 23.13 Diagram of the temporalis lengthening myoplasty as described by Labbe (2009). The insertion into the coronoid is detached, and the
posterior aspect of the muscle is detached from the temporal fossa, allowing the muscle to pivot and lengthening its reach so that the insertion can be
passed beneath the zygomatic arch and can be attached to the oral commissure (arrow).
Fig. 23.12 Diagram based on schematics from Rose (2005) showing how a fascia lata graft (blue) running from the upper and lower lip to the
zygomatic arch may be used to compensate for impairment of function of the levator labii superioris, the zygomaticus muscles, and the risorius.
Soft-Tissue Deformities of the Head and Neck
238

the width of the muscle near the vascular pedicle most strongly
stimulated by the nerve ( Fig. 23.15, Fig. 23.16). Key to the
procedure is the preoperative marking of the patient to decide
on the vector of pull that will be mimicked by the gracilis
(Fig. 23.17). This is challenging because normally there are
multiple vectors from the multiple muscles attaching to the lip,
but only one can be chosen for the gracilis. The muscle is har-
vested simultaneously with the preparation of the recipient site.
The side of the face to receive the muscle is accessed via a “face-
lift” approach in a subcutaneous plane. The buccal fat pad is
removed to aid access to the preferred recipient facial vessels
and to reduce bulk. Particularly careful attention is paid to the
sutures placed to anchor the flap to the deep dermis around the
oral commissure (as normal facial muscles may be expected to
do) and with a line of pull that will tend to mimic a vector some-
where between the zygomaticus muscles and the levator labii
superioris depending on the individual patient characteristics,
and that is symmetric with the contralateral side, where appro-
priate. There should be a low threshold for adjusting them in the
event of unsatisfactory placement (Fig. 23.18). The muscle is
then transferred and sutured in place anteriorly and inferiorly to
the commissural anchoring sutures and posteriorly and superi-
orly to the temporal fascia (Fig. 23.19) and revascularized, and
the neurorrhaphy performed to the chosen recipient. Other
muscles also have been described in the literature, including the
pectoralis minor and serratus anterior. A single-stage latissimus
dorsi flap innervated from the contralateral side via the rela-
tively long thoracodorsal nerve also has been described.
23.7.6 Lower Lip
The muscles supplied by the marginal mandibular branch of
the facial nerve are responsible primarily for lip eversion and
depression, and these features are lost when the nerve is dam-
aged. Static procedures include wedge excision (not indicated
in the pediatric population) and the use of static suspension
slings. In terms of dynamic reconstruction, as before, a cross-
face nerve graft can be used to innervate the damaged nerve or
Fig. 23.14 Image based on radiographs of ba-
rium perfused specimens (in Cormack and
Lamberty, The Arterial Anatomy of Skin Flaps)
showing the vascular anatomy of the gracilis
muscle. It is a Mathes and Nahai type 2 muscle,
and the dominant pedicle and minor pedicles can
be seen, as well as the neural supply from the
anterior obturator nerve. Usually the dominant
pedicle travels with two venae comitantes.
(Adapted from Sharma et al 2016.)
Fig. 23.15 Image of the gracilis in the right thigh. The segment of
gracilis that stimulates most strongly with the nerve stimulator is
identified and dissected from the main body of the gracilis, leaving
behind up to 75% of the width of the gracilis.
Fig. 23.16 Photograph showing the externalized flap, giving an
indication as to its size following the limited segment dissection.
Fig. 23.17 Preoperative markings showing 1. the normal side (N) and
the paralyzed side (P), the nasolabial fold on the right and a
corresponding line on the left, the palpable facial vessels, dots around
the right oral commissure where sutures will be placed, and an arrow
demonstrating the intended line of pull.
Facial Paralysis
239

Fig. 23.18 Key sutures that will attach to the flap are placed at estimated ideal insertion site of the flap (a). The initial attempt results in an
unsatisfactory result with an excessively lateralized nasolabial fold and lip eversion (b), and so the sutures are re-sited, resulting in a more acceptable
outcome (c).
Fig. 23.19 The gracilis is transferred to the recipient site. The anchoring sutures are tied through the grasping “figure-of-8” sutures within the gracilis.
The effect of these grasping sutures is to prevent the anchoring sutures pulling through the gracilis. The muscle is “parachuted” into place.
Soft-Tissue Deformities of the Head and Neck
240

even to neurotize the muscle directly. Regional muscle transfers
have also been described—in particular the anterior belly of
digastric ( Fig. 23.20), which is supplied by the trigeminal
nerve, though neurotizing the transferred anterior belly of
digastric with a cross-facial nerve transfer from the contrala-
teral marginal mandibular nerve to give spontaneous facial
nerve–dependent function has been described. Finally, con-
tralateral balancing procedures may be performed—a myotomy
and botulinum toxin injection.
23.8 Complications
In general, outcomes following free gracilis transfer are very
good, with the vast majority of patients achieving an improved
facial symmetry and a spontaneous smile (where a cross-face
nerve graft has been used); the excursion achieved with the
contralateral face can be 75% of that of the ipsilateral side. The
complication rates are low, and in our unit over a 30-year
period, only 1.6% of cases from 256 free gracilis transfers did
not show an improvement in lateral lip excursion (i.e., either
neurotization of the free tissue transfer failed) and would
require a complete revision of the reconstruction, and only 3.9%
required a minor revision. Very importantly, there is also now
good evidence that facial reanimation surgery makes not only
an objective, metric improvement in facial appearance, but also
a subjective one in terms of the perception of others regarding
the patient.
The management of suboptimal results includes the necessity
for trimming of the muscle or subcutaneous recipient tissue in
an excessively bulky flap. Incorrect positioning or slippage of
the muscle along anchoring sutures is much more di cult to
address. On occasion, these may be adjusted by repositioning,
plication, or by adjustment with slings. However, these fine
adjustments are often more di cult than they may appear and
sometimes the only solution is a complete revision of the flap.
This has significant implications for the patient and their family
and must be discussed with them at length. Other procedures
that may become necessary include contralateral balancing
operations.
23.9 Conclusion
The management of pediatric facial palsy begins with the accu-
rate multidisciplinary assessment of the deficit and acute prob-
lems, the cause and associated problems, the likelihood of
spontaneous recovery, and the psychological and social impact
on the child and their family. After the management of acute
issues (which are uncommon), once there is a decision to oper-
ate, an assessment is made of the surgical options. Which one is
used depends on the exact deficit, but in general in the pediatric
group the problem is the inability to smile. Our preferred option
is a two-stage procedure in which the first stage is a cross-face
nerve graft and the second stage a free gracilis transfer. This is
gone through in detail with the family, and the decision to pro-
ceed is made together with them. The outcomes are generally
good, with the vast majority of patients who have received
the two-stage procedure achieving improved facial symmetry,
developing an ability to smile spontaneously. It also achieves
very satisfactory results for those receiving free gracilis transfers
innervated by the motor nerve to masseter (Fig. 23.21), and
the complication and revision rates are relatively low.
In terms of the future, recent evidence from the rat model
suggests that “supercharging” the nerve graft with a sensory
nerve at the time of grafting can improve nerve regeneration.
Brief periods of electrical stimulation of a proximal nerve stump
can also enhance nerve regeneration. Finally, there are also
potential pharmacological avenues that may improve outcomes
in nerve regeneration, such as geldanamycin and FK-506.
Fig. 23.20 An image of Edgerton’s original picture
(1967) describing the anterior belly of digastric
transfer. The text reads: “When the lower lip is
paralyzed, the asymetry[sic] may be corrected by freeing
the anterior belly of the digastric muscle from the
mandible. A graft of fascia lata may be lashed to the
muscle and split into two tails. Each tail is then threaded
subcutaneously to loop about a bundle of the paralyzed
lip muscle located near the commissure and just lateral to
the midline. The ends of the fascia are returned to the
neck incision, tightened with lip in slight overcorrection
and sutured. As an alternative, the fascia may be sutured
directly to the digastric tendon without freeing the muscle
from the mandible. This latter method gives slightly less
excursion of the lip.”
Facial Paralysis
241

23.10 Key Points
● Management of pediatric facial palsy should be performed in
a multidisciplinary environment including and collaboratively
with the patient family.
● Assessment is to evaluate the possibility of sinister causes, the
chances of spontaneous resolution, the deficit in terms of
function and appearance and reconstructive options.
● The primary problem in children is the loss of an emotionally
spontaneous smile caused by paralysis of the lateral commis-
sure of the lip.
● There are many surgical options. At The Hospital for Sick Chil-
dren in Toronto our preferred option for the lateral lip is a
two-stage procedure: cross-face nerve grafting followed by
gracilis transfer.
Suggested Readings
Carraway JH, Manktelow RT. Static sling reconstruction of the lower eyelid.
Operative Techniques Plast Reconstr Surg.. 1999; 6(3):163–166
Dey JK, Ishii M, Boahene KD, Byrne PJ, Ishii LE. Changing perception: facial re-
animation surgery improves attractiveness and decreases negative facial per-
ception. Laryngoscope. 2014; 124(1):84–90
Freilinger G, Gruber H, Happak W, Pechmann U. Surgical anatomy of the
mimic muscle system and the facial nerve: importance for reconstructive and
aesthetic surgery. Plast Reconstr Surg. 1987; 80(5):686–690
Manktelow RT, Zuker RM. Cross-face nerve graft – the long and short graft:
The first stage for microneurovascular muscle transfer. Operative Tech in
Plast & Recon. 1999; 6(3):174–179
Rubin LR. The anatomy of a smile: its importance in the treatment of facial
paralysis. Plast Reconstr Surg. 1974; 53(4):384–387
Sharma PR, Zuker RM, Borschel GH. Gracilis Free Muscle Transfer in the Treat-
ment of Pediatric Facial Paralysis. (submitted for publication).
Terzis JK, Tzafetta K. “Babysitter” procedure with concomitant muscle trans-
fer in facial paralysis. Plast Reconstr Surg. 1999; 6(3):174–179
Fig. 23.21 Before and after bilateral gracilis muscle transfers innervated by the motor nerve to masseter.
Soft-Tissue Deformities of the Head and Neck
242

24 Scalp, Cheek, and Neck Deformities
Arin K. Greene
Sum m ary
Pediatric scalp, cheek, and neck deformities include: cutis apla-
sia, alopecia, hemifacial atrophy, and webbed neck. Skin lesions
and trauma also may require reconstruction of these areas. In-
tervention is based on the type of deformity and the age of the
patient.
Keywords: cutis aplasia, hemifacial atrophy, webbed neck,
Turner syndrome, pediatric
24.1 Introduction
Reconstruction of pediatric scalp, cheek, and neck deformities
can be performed by several methods. Scalp defects may be
congenital (e.g., cutis aplasia), but more commonly result from
extirpation of lesions or trauma. The most frequent congenital
malformation of the cheek is hemifacial microsomia (covered in
another chapter), followed by progressive hemifacial atrophy.
Neck lesions such as branchial cleft anomalies and thyroglossal
duct cysts usually are managed by pediatric general surgeons or
otolaryngologists. Plastic surgeons are asked to improve soft-
tissue neck deformities, such as webbing associated with Turner
syndrome.
24.2 Diagnosis
Diagnosis of scalp, cheek, and neck deform ities is m ade by
history and physical exam ination. Im aging rarely is neces-
sary, but may be indicated for cutis aplasia or hemifacial
atrophy to determ ine if an underlying osseous abnorm ality
exists. Occasionally, histopathology aids the diagnosis of
scalp lesions.
24.3 Nonoperative Treatment
The primary morbidity of scalp, cheek, and neck deformities is
psychosocial. Although cutis aplasia may require immediate
operative intervention, other disorders can be observed. Timing
of intervention typically involves three periods: (1) infancy, (2)
between 3 and 4 years of age, and (3) late childhood or adoles-
cence. Large lesions of the scalp are best removed during
infancy because scalp redundancy at this time facilitates extir-
pation and reconstruction. If a deformity is likely to cause
decreased self-esteem, then improving the condition between 3
and 4 years of age should be considered. Because long-term
memory and self-esteem begin to form at approximately 4
years of age, correcting a deformity at age 3 often is desired.
Some parents prefer to wait until children are old enough to
decide whether or not they would like to have an operation,
especially if the deformity is minor. Patients typically do not
request a procedure until late childhood or early adolescence
because before this time the fear of an operation outweighs
their desire to improve a deformity.
24.4 Operative Treatment
24.4.1 Scalp
Cutis Aplasia
Cutis aplasia is a rare condition (1/5,000 newborns), and
includes absence of scalp soft tissues, bone, and/or dura.
(Fig. 24.1). The disorder can a ect any area of the body, but
the scalp is the most common site (84%). The defect usually is
along the sagittal suture and the area is covered with a thin
membrane. One-fourth of patients have an underlying osseous
or dural defect and thus are at risk for infection, venous throm-
bosis, and/or hemorrhage. Because cutis aplasia may be associ-
ated with syndromes and other anomalies, patients should be
evaluated for additional medical conditions.
Management of cutis aplasia is based on the depth of the
defect. If the bone is intact, superficial tissues are treated with
local wound care and the area heals secondarily. Alopecia can
be improved at a later date. If a cranial defect is present with
exposed dura, the condition is life-threatening. Operative inter-
vention is necessary within the first few hours after birth to
prevent desiccation of the dura, meningitis, thrombosis of the
sagittal sinus, and/or hemorrhage from exposed veins. If possi-
ble, the area should be closed by wide subgaleal undermining
of scalp flaps. However, most defects are too large to close line-
arly and require a split-thickness skin graft over the dura. The
thin graft is harvested from the gluteal area and is meshed. It is
important to graft the dura before an eschar has formed. Once
an eschar has developed, it is di cult to remove and the child is
at risk for life-threatening hemorrhage and dural injury from
debridement. If an eschar is present, it is best elevated o the
dura using hydrodissection. Rarely, cutis aplasia can result in
exposed brain without dura; the neonate requires emergent
flap coverage of the area.
Fig. 24.1 Infant with cutis aplasia that healed secondarily. Decreased
hair density can be improved with serial excision or tissue expansion.
Scalp, Cheek, and Neck Deformities
243

Because osseous defects spontaneously heal in infancy, cra-
nioplasty is not performed. Most bone gaps will close and rarely
require secondary reconstruction. If a large osseous defect
remains, it can be filled with particulate bone graft any time
after 18 months of age when the dura no longer has the ability
to create new bone.
Following closure of the soft-tissue defect, alopecia can be
managed electively. Because the infant scalp has significant
redundancy during infancy as the brain is rapidly enlarging,
serial excision of the scar or graft should be considered starting
at 6 months of age. If the area is not amenable to serial excision,
then tissue expansion can be performed later in childhood.
Small areas of alopecia can be observed until the child is older
to determine if it will cause psychosocial morbidity.
24.4.2 Skin Lesions
Because most brain growth occurs during the first year of life,
the scalp has unique redundancy during this period. Conse-
quently, large skin lesions are best removed during infancy to
facilitate the procedure and to achieve the most favorable out-
come. I begin excision at 6 months of age when the risk of anes-
thesia is equivalent to an adult. If the lesion is very large and
will take multiple serial resections, I perform the first resection
at 3 months of age ( Fig. 24.2). The operations are performed
at 6-week intervals when the wound has achieved 80% of its
strength, and the adjacent skin has had su cient time to relax.
In some cases, the incision line cannot be completely closed
after widely undermining skin flaps and performing galeal
scoring. Small openings (e.g., 1–2 cm) can be left open to heal
secondarily.
Most scalp lesions can be rem oved by serial excision.
However, som e wounds require skin graft reconstruction if
(1) the lesion is large, (2) the child has m inim al scalp laxity,
(3) the defect is in an area where it is di cult to advance
skin flaps from two directions (e.g., ear), and (4) the lesion
is unable to be partially excised because suturing remaining
diseased tissue together under tension is problem atic (e.g.,
neurofibroma, vascular m alformation; Fig. 24.3). A split-
thickness skin graft contracts, giving a wound that is
approxim ately one-third sm aller than the original defect.
The skin graft then can be rem oved later by serial excision
or tissue expansion.
Another option to reconstruct large defects following lesion
removal is to expand the scalp prior to excision. This is a rea-
sonable approach for nevi, but should not be performed for vas-
cular lesions (e.g., neurofibroma, vascular anomalies) because
tissue expansion can stimulate the disorder by increasing neo-
vascularization; I prefer to remove the lesion, obtain a smaller
abnormality with a skin graft, and then reconstruct the area
secondarily with tissue expansion. I attempt to avoid tissue
expansion whenever possible because it is traumatic to
patients/families and is associated with significant complica-
tions (e.g., infection, extrusion). However, tissue expansion is
the only alternative to reconstruct hair-bearing scalp for large
areas not amenable to serial excision.
Fig. 24.2 Giant congenital nevus of the scalp. To take advantage of scalp laxity in infancy, serial excision of the nevus was initiated at 3 months of age.
(a) Initial appearance with outline of planned resection. (b) Following first-stage excision. (c) Nevus is completely removed after four stages.
Soft-Tissue Deformities of the Head and Neck
244

Fig. 24.3 Large neurofibroma of the scalp. Serial excision was not possible because the tumor could not be sutured to itself under tension. The wound
was too large to be allowed to heal secondarily. Consequently, the lesion was removed in one stage and reconstructed with a skin graft. A thin split-
thickness graft was used to allow maximal contraction of the wound to facilitate later serial excision of the graft or tissue expansion. Placement of
tissue expanders initially was not chosen because of the higher risk of complications, potential stimulation of the tumor, and coverage of a larger
wound compared to reconstruction of a contracted skin graft. (a) Preoperative appearance. (b) Following extirpation of the lesion. (c) Split-thickness
donor site. (d) Bolster dressing placed. (e) Complete skin graft take. Note that part of the wound was closed linearly. (f) Six weeks postoperative
appearance; the area of the skin graft is significantly smaller than the initial wound.
Scalp, Cheek, and Neck Deformities
245

24.4.3 Alopecia
Alopecia can be improved by three methods: (1) serial excision,
(2) tissue expansion, and (3) hair transplantation. If adequate
scalp is present on either side of the alopecia, then the area can
be improved by serial excision of the tissue with poor hair den-
sity (Fig. 24.4, Fig. 24.5). Wide subgaleal undermining and
scoring are necessary. If the area of alopecia is not amenable to
serial excision, then tissue expansion is required (Fig. 24.6,
Fig. 24.7). I place the ports internally and patients return each
week for saline expansion. Hair transplantation is e cacious
for small defects involving the anterior hairline or for scars that
are visible and cannot be narrowed any further (Fig. 24.8).
Donor scalp is harvested from the occipital region, micrografts
are made under 3.5 ×loupe magnification, and the follicles are
transplanted into the recipient site.
24.4.4 Trauma
Traumatic wounds of the scalp are rarely problematic. Small
areas can be allowed to heal secondarily. Larger lacerations
should be closed, if possible, to prevent a wide scar that may
cause visible alopecia (especially in males who wear their hair
shorter). If a defect cannot be closed linearly, it is best to allow
the area to contract and heal secondarily; the scar can be
improved later. Acute rotational flaps, skin grafts, etc., should
be avoided. If a large area of exposed cranium is present, it can
be grafted over the periosteum to obtain a stable wound that
can be reconstructed later. If the periosteum is not present, the
ectocortex may be burred to bleeding endocortex, treated with
negative pressure wound therapy, and the subsequent granula-
tion tissue will accept a skin graft (Fig. 24.9).
Fig. 24.4 Male child developed alopecia following a scalp infection. The condition was improved by serially excising the area of decreased hair density.
(a,b) Preoperative appearance. (c) Outline of first stage excision. (d) Prior to second-stage excision. (e) Markings for second-stage resection. (f)
Following final excision.
Soft-Tissue Deformities of the Head and Neck
246

Fig. 24.5 Adolescent female with alopecia from a burn injury. (a,b) Preoperative appearance. (c) Intraoperative view following staged excision of scar.
(d) Postoperative appearance following the second-stage excision of alopecia.
Fig. 24.6 Adolescent male who suffered a traumatic injury to his ear and scalp. Because the area of alopecia was large and located along the hairline, it
was not a favorable location for serial excision or hair transplantation. (a) Preoperative appearance. (b) Tissue expanded scalp. (c) Scalp flap following
removal of the tissue expander. (d) Inset of expanded scalp flap.
Scalp, Cheek, and Neck Deformities
247

Fig. 24.7 Female child who underwent resection of a skin lesion reconstructed with a skin graft by another surgeon. (a,b) Preoperative appearance. (c)
Two tissue expanders were placed. (d) Following expansion. (e) Expanded scalp flap. (f) Following inset of flap. (g,h) Postoperative result.
Fig. 24.8 Adolescent male with scar alopecia following trauma. Because the area was small and located along the hairline, it was managed with hair
transplantation. (a,b) Preoperative appearance. (c) Donor hair harvested from the occipital scalp. (d) Micrografts prior to transplantation. (e)
Intraoperative view of grafts in the recipient site. (f) Postoperative appearance.
Soft-Tissue Deformities of the Head and Neck
248

24.4.5 Cheek
The most common cheek malformations are associated with
hemifacial microsomia (e.g., macrostomia, hypoplasia) and are
covered in the chapter devoted to that condition. Other cheek
malformations can be associated with facial clefts. The princi-
ples of cheek reconstruction for congenital defects are similar,
regardless of the type of anomaly. Principles will be exemplified
in this chapter by focusing on progressive hemifacial atrophy
(also called Parry–Romberg disease). The condition was first
noted by Parry (1825) and later described by Romberg (1846).
Hemifacial atrophy is progressive and begins during child-
hood; both sides of the face are a ected equally ( Fig. 24.10).
The disease begins at an average age of 9 years and progresses
for 3 to 15 years before “burning out.” One-third of patients
have only skin and subcutaneous involvement and present at
an average age of 15 years. Two-thirds of patients exhibit skele-
tal deficiency and develop the condition at an average age of 5
years. One-fourth of patients have changes in skin pigmentation
and also may have eyebrow alopecia. Patients often exhibit a
localized area of atrophy of the forehead, referred to as a coup
de sabre (“cut of the sword”). Although the etiology of the dis-
ease is unknown, it may be a variant of scleroderm a. It is
hypothesized that a lymphocytic neurovasculitis occurs along
the trigeminal nerve.
Reconstruction should not be considered until the disease
has completed its progression; intervention usually is started
12 months after the condition has stabilized. Many di erent
techniques have been described to augment the deficient face:
adipose grafts, adipose-dermal grafts, dermal substitutes, allo-
plastic materials, free tissue transfer. Any of these techniques
are reasonable, and may be based on the preference of the sur-
geon. Minor deficiencies are more likely to be amenable to
grafting, while major hypoplasia may require free tissue trans-
fer; local–regional flap transfer generally is not an option.
If underlying skeletal hypoplasia is suspected, then computed
tomography can help plan reconstruction. Frontal bone,
zygoma, maxilla, or mandible deficiency can be enhanced with
onlay bone graft or alloplastic material. Patients with orbital
deficiency may require floor implants to correct enophthalm os.
A severely hypoplastic maxilla or mandible may necessitate an
orthognathic procedure after skeletal maturity has occurred (e.
g., 16 years in females and 18 years in males).
If a patient requires an incision to remove abnormally pig-
mented skin, I prefer to use a thick dermal substitute rather
than fat grafting because acellular dermis does not resorb and
gives a more predictable outcome ( Fig. 24.11). In addition,
some reports have shown that fat grafting for progressive hemi-
facial atrophy has more resorption compared to other recipient
sites. If the patient’s occlusion is normal, I augment facial bones
Fig. 24.9 Scalp defect following trauma. (a) Preoperative appearance illustrates absence of periosteum and exposed cranium. (b) Granulation tissue
generated after burring of the ectocortex to punctate bleeding from the diploic space followed by negative pressure wound therapy. (c) Split-
thickness skin graft placed over granulation tissue. (d) Healed wound amenable to secondary reconstruction with tissue expansion.
Scalp, Cheek, and Neck Deformities
249

with porous polyethylene (Medpor) rather than bone grafts
because there is less resorption and no donor site morbidity.
Most patients with hemifacial atrophy can be managed by aug-
menting the bone and soft tissue with alloplastic material and
grafts. Free tissue transfer should be reserved for very severe
patients; the scapular and parascapular flaps are most com-
monly used.
24.4.6 Neck
Pediatric plastic surgeons are consulted to improve soft-tissue
deformities of the neck. The most frequent is webbing (also
called pterygium colli) from Turner syndrome. Turner syndrome
a ects 1/3,000 females and results from sex chromosome
monosomy (45, X). Although the cause of the web is unknown,
it may result from an intrauterine macrocystic lymphatic mal-
formation that expands the skin, deflates prior to birth, and
leaves residual tissue and a lowered hairline. The web extends
from the mastoid to the clavicle. Other features of Turner syn-
drome include lymphedema (60%), short stature, amenorrhea,
low-set ears, cardiovascular anomalies (50%), thyroid disorders,
renal anomalies, and gonadal dysgenesis.
Several procedures have been described to improve the
webbed neck deformity, including Z-plasty, “butterfly” correc-
tion, and various flaps. I believe Z-plasties should be avoided
because the scars are placed anteriorly and the abnormal
hairline is not corrected. The major principles of reconstruction
of this defect are (1) remove the abnormally positioned hair
on the lower neck, (2) improve neck contour, and (3) position
the scars so they are least visible on frontal view. To achieve
these goals, I use a posterior neck approach, resection of a large
area of abnormal hair and skin, elevation of an anterior skin
flap, and repositioning of the skin posteriorly (Fig. 24.12). The
technique is similar to that described by Menick et al in 1984.
This procedure hides the incision in the hairline and posterior
neck; scars are not visible on front view. If the scars widen on
the neck, they can be secondarily narrowed. In my experience,
children do not present for correction of their webbed neck
until late childhood or early adolescence when their appear-
ance becomes more important to them.
Fig. 24.10 Progressive hemifacial atrophy. (a,b)
Preoperative appearance. (c,d) Early postoperati-
ve result following reconstruction.
Soft-Tissue Deformities of the Head and Neck
250

24.5 Complications
The most frequent unfavorable outcome following reconstruc-
tion of scalp and neck deformities is widened scars because of
significant tension. Scalp scars can cause visible alopecia, espe-
cially in males who have shorter hair. Alopecia can be mini-
mized by maintaining sutures for several weeks, and can be
corrected by narrowing the scar secondarily when there is less
tension on the wound. After reconstruction of a webbed neck
deformity, the scars also can widen because the incision lines
are under significant tension. They can be narrowed seconda-
rily. Wound dehiscence, bleeding, or infection are uncommon.
24.6 Conclusion
Pediatric scalp, cheek, and neck disorders can be reconstructed
by many techniques. Generally, procedures as low on the recon-
structive ladder as possible should be employed. Because the
infant scalp has unique skin laxity, consideration should be
Fig. 24.11 Reconstruction of progressive hemifacial atrophy. The patient underwent (1) excision of atrophied and hyperpigmented skin from the
forehead and cheek with linear closure, (2) augmentation of the forehead and cheeks with layered acellular dermis through the areas of skin that were
excised, (3) onlay mandible and chin implants with porous polyethylene, (4) improvement of the right upper lip deficiency using a dermal graft
harvested from the abdomen, (5) contour of the lower lip by excision of mucosa/submucosa from the left lower lip using a transverse mucosal incision
and then using the material as a graft to the right lower lip, and (6) hair transplantation to the right eyebrow. (a) Intraoperative markings. (b) Acellular
dermis used to augment the forehead and cheek. (c) Dermal graft inserted into right upper lip. (d) Medpor mandible and chin implants placed on the
right side. (e) Occipital scalp used for hair transplantation. (f) Micrografts placed into right medial eyebrow. (g) Forehead “coup de sabre” corrected by
resection of the hypoplastic skin, advancement of adjacent forehead, and placement of acellular dermis underneath the area. (h) Intraoperative
appearance at the end of the procedure. Bolsters were used to secure acellular dermis under the subcutaneous tissue of the cheek.
Fig. 24.12 Management of webbed neck. (a) Child with Turner syndrome. (b) Marking of skin excision. (c) Following resection and wide anterior
undermining of the anterior skin flap. (d) Posterior inset of anteriorly raised skin flaps. (e) Postoperative appearance.
Scalp, Cheek, and Neck Deformities
251

given to extirpation of lesions/alopecia during this period. The
major morbidity of these disorders is psychosocial, and thus
correcting the problem before 4 years of age often is requested.
Progressive hemifacial atrophy must “burn out” before recon-
struction. Some families will prefer to wait until the child is
older when the patient can participate in the decision to pro-
ceed with an operation.
24.7 Key Points
● Cutis aplasia usually can be allowed to heal secondarily; if the
dura is exposed, emergent split-thickness skin grafting is
necessary.
● Resection of scalp lesions or alopecia is facilitated during the
first year of life because of significant skin redundancy.
● Most scalp lesions can be removed with serial excision and do
not require tissue expansion.
● Progressive hemifacial atrophy may be improved by several
methods; grafts are usually su cient, but free tissue transfer
may be necessary for severe disease.
● Correction of a webbed neck should be performed by skin
resection and posterior positioning of anterior skin flaps to
avoid scars on frontal view; Z-plasties should be avoided.
Suggested Readings
Menick FJ, Furnas DW, Achauer BM. Lateral cervical advancement flaps for
the correction of webbed-neck deformity. Plast Reconstr Surg. 1984; 73
(2):223–229
Pensler JM, Murphy GF, Mulliken JB. Clinical and ultrastructural studies of
Romberg’s hemifacial atrophy. Plast Reconstr Surg. 1990; 85(5):669–674, dis-
cussion 675–676
Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and parascapu-
lar flaps for cheek reconstruction. Plast Reconstr Surg. 1992; 90(6):959–971
Hunt JA, Hobar PC. Common craniofacial anomalies: conditions of craniofacial
atrophy/hypoplasia and neoplasia. Plast Reconstr Surg. 2003; 111(4):1497–
1508, quiz 1509–1510
Silberstein E, Pagkalos VA, Landau D, et al. Aplasia cutis congenita: clinical
management and a new classification system. Plast Reconstr Surg. 2014; 134
(5):766e–774e
Hassanein AH, Rogers GF, Greene AK. Management of challenging congenital
melanocytic nevi: outcomes study of serial excision. J Pediatr Surg. 2015; 50
(4):613–616
Soft-Tissue Deformities of the Head and Neck
252

IV
Part IV
Trunk and Lower Extremity
25 Macromastia

254
26 Gynecomastia

258
27 Breast Asymmetry

264
28 Anterior Trunk Disorders

271
29 Posterior Trunk Disorders

277
30 Genital Anomalies

283
31 Lower Extremity

292

25 Macromastia
Laura C. Nuzzi and Brian I. Labow
Sum m ary
Macromastia is a common adolescent breast disorder character-
ized by unilateral or bilateral breast hypertrophy, often result-
ing in significant functional impairment and negative quality of
life. Onset of adolescent macromastia typically occurs shortly
after menarche, usually between the ages of 9 and 15, and is
distinguished by considerable breast growth out of proportion
to the adolescent’s frame. The vast majority of patients with
macromastia report musculoskeletal pain, painful bra strap
grooving, as well as di culty exercising and participating in
sports. Apart from physical symptoms, many patients experi-
ence psychosocial distress manifesting in poor mental health,
low self-esteem, and increased disordered eating thoughts and
behaviors relative to their peers.
Currently, there are no standardized treatment guidelines
for adolescents with macromastia. Available non-operative
treatments include physical therapy, weight loss and nutrition
counsel, hormonal treatments, and ongoing psychological ma-
nagement. However, the e cacy of these treatments is variable,
and they often do not completely alleviate symptoms. Macro-
mastia can be successfully treated with early surgical interven-
tion in the form of reduction mammaplasty, though this option
is often hindered by various barriers to treatment specific to
the adolescent patient. The most widely employed surgical
technique in the United States is the Wise pattern resection
around an inferiorly based pedicle. Associated musculoskeletal
symptoms improve almost immediately following reduction
mammaplasty, with breast appearance continuing to improve
for several months. Although a relatively safe operation, minor
complications related to wound healing in the early postopera-
tive period are common. Conversely, major complications such
as tissue loss, loss of sensation, and hemorrhage are very rare.
Keywords: macromastia, breast hypertrophy, adolescent, reduc-
tion mammaplasty, breast overgrowth, Wise pattern resection
25.1 Introduction
Macromastia is a common adolescent breast disorder in which
the glandular tissue of one or both breasts exhibits hypertrophy
(Fig. 25.1). Onset frequently begins shortly after menarche
and is marked by considerable breast growth out of proportion
to the adolescent’s frame. Aesthetic concerns aside, benign
breast overgrow th can result in significant functional impair-
ment and is associated with negative quality of life. The major-
ity of patients present with moderate to severe musculoskeletal
pain, bra strap shoulder grooving and bruising, and di culty
when exercising and participating in sports. Adolescents with
macromastia are often targets of teasing and harassment and
unwanted sexual attention, and as such, many patients su er
from poor mental health and low self-esteem.
Although macromastia can be successfully treated with early
surgical intervention, there are several barriers to treatment
unique to the adolescent patient. For example, parents, physicians,
and surgeons may be reluctant to o er surgery despite debilitat-
ing symptoms, and in some cases insurers set age and weight
restrictions for the procedure. Reduction mammaplasty is a well-
tolerated procedure with a high satisfaction rate in appropriate
patients. In general, patients should be nonsmokers with suppor-
tive families and also emotionally and intellectually mature
enough to understand the risks and benefits of surgery. Although
minor complications related to wound healing are common,
major complications such as tissue loss, loss of sensation, and
hemorrhage are very rare.
25.2 Diagnosis
Onset of adolescent macromastia occurs shortly after menarche,
most commonly between the ages of 9 and 15 years. During
this time, the breasts may quickly grow disproportionate to the
adolescent’s frame and may appear ptotic with striae. In rare
cases of virginal breast hypertrophy, rapid and progressive
breast development may begin with onset of thelarche and
necessitate early surgical intervention. Although breast over-
growth may be noted early by the pediatrician, parent, and pa-
tient, the stigmatization of adolescent breast surgery may delay
referral of patients with suspected macromastia to the plastic
surgeon. By the time the adolescent presents to the plastic sur-
geon, she may be considerably symptomatic for several years.
Patients with symptoms referable to heavy, ptotic breasts
should undergo a complete history, physical examination, and
assessment of symptomatology (Box 25.1). A formal “diagnosis”
of macromastia can be made using the Schnur Sliding Scale,
which examines the relationship between estimated breast
Fig. 25.1 A 17-year-old female with severe macromastia, bra strap
grooving, and skin irritation is visible.
Trunk and Lower Extremity
254

resection mass and the patient's calculated body surface area
(BSA), in order to determine whether the indications for reduc-
tion mammaplasty are primarily medical or cosmetic. A com-
mon threshold for insurance coverage is a minimum 500 g of
resected tissue per breast, although this may be less in petite or
short-statured women.
Box 25.1 Indications for reduction mammaplasty
in adolescents
1. Breast symptomatology
a) Shoulder grooving and bruising
b) Inframammary intertrigo
c) Breast ptosis
d) Breast striae
2. Associated musculoskeletal pain
a) Lower and upper back
b) Shoulder
c) Neck
d) Arm
e) Breast
3. Physical impairment
a) Daily work, school, life activities
b) Exercise and sporting activities
c) Secondary scoliosis or postural defects
4. Psychosocial impairment
a) Mental health
b) Self-esteem
c) Disordered eating thoughts and behaviors
d) Di culty finding appropriately fitting clothes and bras
5. Anthropometric characteristics
a) Schnur Sliding Scale threshold for BSA
Abbreviation: BSA, body surface area (m2).
Associated musculoskeletal pain—including, but not limited to,
the upper and lower back, shoulders, neck, arms, and breasts—
should be documented for insurance purposes. Inframammary
fold intertrigo, shoulder grooving and bruising from bra straps,
and discomfort when exercising should be assessed and noted.
During the physical examination, presence of multiple or giant
fibroadenoma should be ruled out, particularly in patients pre-
senting with unilateral macromastia or painful, tender breasts.
Adolescents with macromastia may exhibit poorer mental
health, lowered self-esteem, and increased disordered eating
thoughts and behaviors relative to their peers. Positive exam
findings for diminished mental health status, self-esteem, and
disordered eating behaviors and obesity should be addressed.
The surgeon should also evaluate the patient’s skeletal and psy-
chological maturity when considering surgical intervention.
The potential for additional breast growth in pubertal patients
must be considered and discussed with the patient and parent,
but should not absolutely preclude surgery.
25.3 Nonoperative Treatment
Currently, there are no standardized treatment guidelines for
adolescent macromastia. Plastic surgeons may delay reduction
mammaplasty due to concerns of additional breast growth and
the need for reoperation, patient obesity and potential postope-
rative complications, and the potential negative psychological
e ects of breast surgery on adolescents. Age and breast volume
cuto s set by third-party payors may also delay surgery.
Patients who are not yet skeletally or emotionally ready for sur-
gery should be followed by the plastic surgeon for exacerbation
of symptoms and developmental maturity. Sympathetic reas-
surance and counsel with respect to future surgical interven-
tion should be provided during these visits. Additionally, if the
patient has not been professionally fitted for a bra, she should
be encouraged to do so.
The e cacy of estrogen antagonists and steroidal progestins
—such as tamoxifen, dydrogesterone, and medroxyprogester-
one citrate—to halt breast growth and reduce symptomology is
variable. As such, nonoperative treatment should primarily con-
cern minimizing the patient’s physical and psychosocial dis-
comfort until surgery can be achieved. Musculoskeletal pain
may be temporarily alleviated with referral to physical therapy,
and can also be a requirement for reduction mammaplasty cov-
erage by some third-party payors. Weight loss and nutrition
counsel may be another requirement for coverage and may
o er additional benefits given that adolescent patients with
macromastia are more likely to su er from obesity and disor-
dered eating behaviors.
The psychosocial component of macromastia must not be
ignored. Adolescent patients with diminished em otional well-
being, self-esteem , and mental health should be referred for
ongoing psychological m anagement. During clinic visits, the
plastic surgeon should assess current m ental status, docu-
m ent worsening of symptom s, and m ake referrals when nec-
essary. Finding properly fitted bras and clothing also serves
as a considerable source of stress for m any adolescent m ac-
rom astia patients. The plastic surgeon m ay wish to familiar-
ize themselves with specialty clothing and bra outlets that
provide greater sizing options and direct patients when
necessary.
25.4 Operative Treatment
Reduction mammaplasty is a safe operation requiring a general
anesthetic, and may be done on an outpatient basis or a single-
night stay. The goal of reduction mammaplasty is to resect
excess redundant skin, gland, and adipose tissue of the breast.
The breast is reshaped and nipple areola complex (NAC) is
repositioned and resized to provide proper position and con-
tour. Care must be taken to preserve breast mound projection
when repositioning and resizing the length of the inframam-
mary fold length and NAC diameter. Nipple placement should
be at or slightly above the inframammary fold, and is crucial in
maintaining aesthetic and three-dimensional appearance of the
breast.
Reduction mammaplasty can be performed using a variety of
pedicles and incision patterns. The m ost widely employed
technique in the United States is the Wise pattern resection
around an inferiorly based pedicle. The Wise pattern is ver-
satile and particularly advantageous for large reductions,
ptotic breasts, patients w ith poor skin quality, and in
instances requiring considerable nipple repositioning. This
Macromastia
255

technique is m ost likely to leave sensation and ability to
lactate intact; however, som e feel the potential for visible
scarring and lim ited breast projection is greater using the
Wise pattern ( Fig. 25.2, Fig. 25.3).
25.4.1 Postoperative Management
Postoperative routines vary by surgeon. However, following
closure, the surgical site is often covered w ith steri-strips,
absorbent dressings, and a surgical support bra. At the first
postoperative visit, the dressing is rem oved and the surgical
site checked. Typically, patients require 3 to 5 days of pre-
scription pain medication and are out of school or work for
roughly 1 week. Exercise and lifting should be avoided for
the first 6 weeks following surgery, after which full activity
can be resumed. Similarly, patients should use a supportive
sports bra and avoid a bra with an underwire for 6 weeks
following reduction mam maplasty.
Associated musculoskeletal symptoms improve almost
immediately following reduction mammaplasty, with breast
appearance continuing to improve for several months. Lateral
breast sensation normalizes around the sixth month mark;
however, scar maturation may take 1 to 2 years to achieve opti-
mal appearance. In this population, it may be advantageous to
follow patients at least several times during the first postopera-
tive year and annually thereafter.
Fig. 25.2 (a) A 16-year-old with moderate bilat-
eral adolescent macromastia, DD cup-size. (b)
Nine months following Wise pattern reduction
mammaplasty, C cup-size, 750 total grams
removed.
Fig. 25.3 (a) An 18-year-old with severe bilateral
adolescent macromastia, H cup-size. (b) Two and
half years following reduction mammaplasty, D
cup-size, 4,530 total grams removed.
Trunk and Lower Extremity
256

25.5 Complications
Although reduction mammaplasty is a relatively safe and com-
mon procedure, roughly 40 to 50% of patients will experience
some complication. Despite these complications, patient satis-
faction following reduction mammaplasty remains high. Early
postoperative complications are more frequent, but usually
minor. Wound dehiscence and delayed wound healing present
in 10% of patients. Additional clinic visits may be warranted for
wound dehiscence worrisome to the patient and can be man-
aged with dressing changes. Exposed sutures causing pain and
minor skin irritation from steri-strips are also common. Rates
of infection requiring oral antibiotics and drainage are less than
1%. Excessive bleeding, seroma, and hematoma requiring reope-
ration and evacuation are rare. Risks of nipple ischemia and fat
necrosis are exceedingly low in the adolescent population.
Patients should be followed closely during the first postope-
rative year and beyond to assess longer term complications.
Diminished nipple and lateral breast sensation is to be expected
during the early healing period. Patients should regain sensa-
tion within the first 6 months; however, a subset of women will
have persistent partial or complete loss of breast and/or nipple
sensation following reduction mammaplasty.
Keloid and hypertrophic scar formation may be noted after
several months of wound healing. Scar massage, silicon sheet-
ing, and eventually corticosteroid injections can be employed in
the clinic setting to decrease the contour of existing keloids and
to diminish burning and pruritic symptoms.
A considerable number of adolescents present preoperatively
with mild to moderate breast asymmetry in addition to macro-
mastia, and in fact a degree of NAC or breast asymmetry is to be
expected postoperatively. As the breast skin relaxes and glandu-
lar tissue settles after surgery, the breast may appear to “bot-
tom out.” This results in a breast where the nipple appears to
rest too high above the inframammary fold. In general, it is best
to ensure that the nipple is not positioned too high at the time
of surgery. This is especially true in patients with thin skin.
Revisional procedures can correct size and position asymme-
tries of the breast and NAC, but these should be considered
after the first postoperative year. Dog-ears, or redundant skin at
the suture sites, can be addressed through limited revisions
under local anesthesia.
Unique to the adolescent patient is the risk of reoperation
due to continued pubertal or future gestational breast growth.
Although this can occur, age alone should not be viewed as an
absolute contraindication to surgery. For many patients, the
physical and psychosocial benefits of early surgical intervention
may far outweigh the risk of a repeat procedure later in life. It
should be noted, however, patients with a 1-year history of
stable breast size typically do not exhibit considerable breast
regrowth following reduction mammaplasty. An additional
concern of referring pediatricians, plastic surgeons, and
patients alike is the e ect of reduction mammaplasty on an
adolescent’s ability to lactate and produce su cient milk vol-
ume in the future. Postoperative lactation ability may be associ-
ated with surgical technique. All e orts should be made to
spare the neurovascular structures of the ductal breast tissue.
Postoperative patients are believed to have a 65% lactation
success rate; however, many patients may require formula
supplementation.
25.6 Conclusion
Adolescent macromastia is a common hyperplastic breast
disorder characterized by breast overgrow th disproportionate
to the patient’s frame. Patients may be highly symptomatic and
present with musculoskeletal pain, breast striae, and painful
shoulder grooving and bruising from bra straps. Macromastia
can result in significant functional and psychosocial impair-
ment and is associated with negative health-related quality of
life. However, the adolescent patient faces several unique bar-
riers to treatment that may delay referral and surgical interven-
tion. Age and potential for breast regrowth and reoperation
should not preclude surgery in this otherwise healthy patient
population.
Early surgical intervention may alleviate and prevent the
exacerbation of physical and psychosocial symptoms into adult-
hood. In many cases, this resolution of symptoms may outweigh
the risk of reoperation later in life. Reduction mammaplasty in
the adolescent is a well-tolerated procedure with a high rate of
satisfaction. Postoperative complications are common, but typi-
cally minor and can be largely managed in the clinic setting.
25.7 Key Points
● Macromastia is a common hyperplastic adolescent breast dis-
order resulting in considerable unilateral or bilateral breast
overgrowth.
● Patients may su er from functional and psychosocial impair-
ments due to their breast size. Macromastia is highly associ-
ated with moderate to severe musculoskeletal pain.
● Reduction mammaplasty is the most e ective treatment for
macromastia in appropriately selected patients.
● Age and potential for additional growth should not preclude
surgery; early intervention can prevent the exacerbation of
physical and psychosocial symptoms in adulthood.
● Postoperative complications are common, but minor, and can
be largely managed in the clinic setting.
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cents: a cross-sectional study. Pediatrics. 2012; 130(2):e339–e346
Lee MC, Lehman JA , Jr, Tantri MD, Parker MG, Wagner DS. Bilateral reduction
mammoplasty in an adolescent population: adolescent bilateral reduction
mammoplasty. J Craniofac Surg. 2003; 14(5):691–695
de la Torre JI, Vasconez LO. Macromastia and reduction mammaplasty. In:
Bland KI, Copeland EM, eds. The Breast: Comprehensive Management of
Benign and Malignant Disease. 4th ed. Vol 2. St. Louis, MO: Saunders;
2004:877–885
McMahan JD, Wolfe JA, Cromer BA, Ruberg RL. Lasting success in teenage
reduction mammaplasty. Ann Plast Surg. 1995; 35(3):227–231
Saleem L, John JR. Unfavourable results following reduction mammoplasty.
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Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP. Reduction mammaplasty:
cosmetic or reconstructive procedure? Ann Plast Surg. 1991; 27(3):232–237
Schnur PL. Reduction mammaplasty: the Schnur Sliding Scale revisited. Ann
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Wise RJ. A preliminary report on a method of planning the mammaplasty.
Plast Reconstr Surg (1946). 1956; 17(5):367–375
Xue AS, Wolfswinkel EM, Weathers WM, Chike-Obi C, Heller L. Breast reduc-
tion in adolescents: indication, tim ing, and a review of the literature. J Pediatr
Adolesc Gynecol. 2013; 26(4):228–233
Macromastia
257

26 Gynecomastia
Laura C. Nuzzi and Brian I. Labow
Sum m ary
Gynecomastia is a common finding among healthy adolescent
boys. Benign excess glandular breast tissue is the hallmark of
gynecomastia. Severity ranges from a pu y appearing nipple
areolar complex (NAC) to marked enlargement and ptosis.
Gynecomastia may result in significant distress, and diminished
self-esteem and mental health.
A comprehensive history and physical examination underpin
the assessment of gynecomastia; these may be supplemented
by laboratory studies and imaging. A thorough history must
include a medications history, an inquiry into recreational and
performance enhancing drugs, an exploration of symptoms of
endocrine disease, and a systems review. Breast palpation is
crucial and should aim to determine the degree of glandular
and adipose involvement, and the presence of pain, tenderness
and breast masses.
The majority of cases are idiopathic and self-resolving; these
patients are managed with reassurance and follow-up until res-
olution. Other patients experience gynecomastia secondary to
pathological processes or pharmacological side e ects, which
may be amenable to medical intervention. Non-operative inter-
ventions include the use of compression shirts, nutritional ma-
nagement, medication review, and referral to endocrine
services for specialized treatment. Surgical intervention may be
necessary in response to gynecomastia that is severe, distress-
ing, or persistent. Operative treatment may be a combination of
mastectomy, mastopexy, liposuction, and lipectomy. Satisfac-
tion with surgery remains high among patients despite rela-
tively frequent minor post operative complications.
Keywords: gynecomastia, breast, mastectomy, liposuction,
lipectomy
26.1 Introduction
Pubertal gynecomastia is a common finding among otherwise
healthy adolescent boys. The condition is marked by benign
excess glandular breast tissue, although all breast mounds con-
tain gland, fat, and skin to a variable degree. Severity encom-
passes a broad spectrum of presentations ranging from a pu y
appearing nipple areolar complex (NAC) to marked breast
enlargement and ptosis. Adolescents with gynecomastia of
any severity may su er from poor mental health and low
self-esteem. It should be noted that most boys will exhibit
some degree of gynecomastia during adolescence, with the
majority of cases self-resolving 2 to 3 years after onset.
Although pubertal gynecomastia is largely idiopathic, proper
physical examination and workup is essential to rule out poten-
tial underlying pathological causes.
Most idiopathic cases of mild gynecomastia can be managed
with sympathetic reassurance and yearly follow-up until reso-
lution. The e cacy of medical intervention is variable and
dependent on etiology. Persistent or distressing gynecomastia
may warrant surgical intervention, with technique determined
by the extent of hypertrophy and skin excess. The goal of treat-
ment is to reduce the projection of the breast mound and NAC.
Excision of redundant skin and reduction of NAC size may also
be performed in cases of moderate to severe gynecomastia. Sur-
gical complications are more common, but typically minor in
patients with severe gynecomastia who undergo larger tissue
resections.
26.2 Diagnosis
26.2.1 Presentation
Gynecomastia is a common finding among adolescent boys,
particularly during Tanner stages 2 and 3. It is estimated that
by the age of 14 years, 70% of all adolescent boys will exhibit
some degree of gynecomastia. The majority of cases are idio-
pathic and self-resolving, with over 90% of a ected boys show-
ing complete resolution of symptoms within 3 years of onset.
As a result, gynecomastia is often managed in the pediatric pri-
mary care setting. Referral to the plastic surgeon, however, may
be necessary in cases of distressing, persistent, or considerable
gynecomastia.
Male breast hypertrophy can be familial and may present
unilaterally or with some degree of asymmetry in up to one-
third of patients. Unlike macromastia, formal “diagnosis” of
gynecomastia does not require meeting a threshold mass of tis-
sue resected. The degree of breast hypertrophy in gynecomastia
may instead span a range of mild to severe. As such, gyneco-
mastia is described using a graded scale often used by third-
party payors to determine insurance coverage eligibility (Box
26.1; Fig. 26.1). Grade I gynecomastia is the mildest form,
with minimal hypertrophy (<250 g) without ptosis. Grade II
gynecomastia is defined by moderate hypertrophy (250–500 g)
without ptosis. Grade III gynecomastia (>500 g) describes
severe hypertrophy with skin excess, and is marked by mild
ptosis. Grade IV gynecomastia (>500 g) is the most severe with
considerable hypertrophy, skin excess, and moderate to severe
ptosis. It should be noted that gynecomastia of any grade may
result in significant distress and diminished self-esteem and
mental health.
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258

Fig. 26.1 Graded severity of gynecomastia. (a,b)
Grade I: mild breast hypertrophy without ptosis.
(c,d) Grade II: moderate breast hypertrophy
without ptosis. (e,f) Grade III: moderate breast
hypertrophy with mild ptosis and skin excess. (g,
h) Grade IV: severe breast hypertrophy with
considerable ptosis and skin excess.
Gynecomastia
259

Box 26.1 Graded Severity of Gynecomastia
● Grade I
○ <250 g hypertrophy excess per side
○ Minimal glandular, adipose involvement
○ No skin involvement or ptosis
○ Grade Ia: breast mound composition primarily adipose
tissue
○ Grade Ib: breast mound composition primarily glandular
tissue
● Grade II
○ 250–500 g hypertrophy excess per side
○ Moderate glandular, adipose involvement
○ No skin involvement
○ No ptosis
○ Grade IIa: breast mound composition primarily adipose
tissue
○ Grade IIb: breast mound composition primarily glandular
tissue
● Grade III
○ >500 g hypertrophy excess per side
○ Moderate to severe glandular, adipose involvement
○ Mild to moderate skin involvement
○ Mild ptosis (grade 1)
● Grade IV
○ >500 g hypertrophy excess per side
○ Severe glandular, adipose involvement
○ Moderate to severe skin involvement
○ Moderate to severe ptosis (grade II or III)
Source: Adapted from Rohrich RJ, Ha RY, Kenkel JM, Adams WP
Jr. Classification and management of gynecomastia: defining
the role of ultrasound-assisted liposuction. Plast Reconstr Surg
2003;111:909–923.
True gynecomastia is a proliferation of male glandular breast
tissue, and should be distinguished from pseudogynecomastia
in which the majority of the breast mound is secondary to
excess adipose tissue. Both tissue types, however, are present to
varying degrees in patients with true pubertal gynecomastia.
Adolescent gynecomastia is highly associated with obesity.
Excess peripheral adipose tissue can contribute directly to the
size of the breast mound. Additionally, the presence of elevated
aromatase in adipose tissue can result in glandular overgrowth
by stimulating the conversion of androgens to estrogen.
Regardless, it should be emphasized that it is usually the size
and contour of the breast mound rather than its relative com-
position that is concerning to patients.
26.2.2 Physical Exam and Workup
All patients presenting to the plastic surgeon with suspected
gynecomastia should undergo a complete history and physical
exam. A breast exam should be performed to determine the
degree of glandular and adipose tissue involvement and to
assess for pain, tenderness, and palpable breast masses. Patients
are most likely to experience pain and tenderness during the
first 6 months of symptoms when the breast mound is under-
going ductal proliferation. Presence of glandular involvement
can be easily palpated on exam as a rubbery, mobile disc lying
beneath the NAC. The majority of adolescents presenting with
gynecomastia are otherwise healthy. Pubertal physiologic gyne-
comastia absent of any risk factors or findings on physical
examination can be followed without additional studies.
Prescription and illicit drug use should be assessed. Drug-
induced adolescent gynecomastia is commonly associated with
excessive marijuana and alcohol use, and to a lesser extent, H2
receptor antagonists, psychoactive agents, cardiovascular drugs,
antiandrogens, chemotherapeutics, antibiotics, and antiretrovi-
rals. The use of anabolic steroids and over-the-counter nutra-
ceuticals to improve strength or athletic performance should
also be discussed.
Additional studies should be performed for patients with
persistent or progressive gynecomastia, breast hypertrophy
arising during late puberty, palpable testicular or breast masses,
hypogonadism, or delayed puberty. Laboratory studies may
include free testosterone (T), luteinizing hormone, follicle-stim-
ulating hormone, estradiol, and beta-human chorionic gonado-
trophin tests. Low testosterone with or without elevated
gonadotrophin levels may be indicative of Klinefelter syndrome
(46, XXY). A karyotype should be obtained in cases where tes-
ticular atrophy or lab values are suggestive of hypogonadism. In
rare suspected cases of renal, hepatic, or thyroid disease, liver
function tests and calcium, creatinine, and thyroid-stimulating
hormone assays may be necessary.
Imaging of the breast is rarely performed except when a
suspicious mass is noted on exam or if required to document
glandular excess. Of note, adolescent male breast cancer is
extremely rare and idiopathic gynecomastia is not associated
with an elevated risk.
26.3 Nonoperative Treatment
As gynecomastia is largely idiopathic and self-resolving, the
majority of cases may be managed with support and sympa-
thetic reassurance. These patients should be monitored periodi-
cally every 6 to 12 months until resolution. Gynecomastia is
strongly associated with poor psychological well-being and
self-esteem, and the plastic surgeon should use clinic visits to
monitor mental health, document changes, and make referral
for psychological management when necessary.
Providers may recommend the use of compression shirts
worn under clothing as an immediate, inexpensive nonmedical,
and nonsurgical means to minimize the contour of the chest
and provide support. This may be especially beneficial for
patients who report teasing, bullying, or poor self-esteem as a
result of their chest size.
Gynecomastia is associated with obesity, and treatment
should include weight loss and nutritional management.
Patients with moderate to severe glandular and skin involve-
ment should be advised that although weight loss may be bene-
ficial for a myriad of health reasons, weight loss alone may not
be su cient to address the problem. Weight loss, however, may
reduce chest size for patients with pseudo-gynecomastia in
which the majority of the breast mound is composed of adipose
tissue. These patients may wish to seek surgical intervention
following weight loss for excision of any remaining glandular
tissue and redundant skin. A reduction of trunk adipose during
early puberty, closer to the onset of presentation, may abrogate
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260

glandular hypertrophy caused by paracrine signaling. As such,
younger obese patients should be encouraged to lose weight as
a means to curtail future breast grow th.
Gynecomastia secondary to drug use should be managed by
discontinuing the use of illicit or performance-enhancing drugs,
and counsel with the prescribing physician in cases of prescrip-
tion medication–induced overgrowth. Gynecomastia persisting
for 12 months following changes in drug use should receive addi-
tional workup and counsel with respect to surgical intervention.
Patients with suspected hormonal causes should be referred
to an endocrinologist with experience in treating the adoles-
cent patient. Medical treatment for endocrine-related gyneco-
mastia may include anti-estrogens or aromatase inhibitors,
with androgen use falling out of favor. E cacy is highly variable
and patients should be advised that pharmacotherapy is most
e ective during early onset before fibrous tissue replaces gland.
Surgical intervention should be discussed in cases of distressing
gynecomastia secondary to underlying medical cause when sat-
isfactory improvement cannot be achieved with pharmacother-
apy alone.
26.4 Operative Treatment
Surgical intervention may be warranted in cases of persistent
gynecomastia resulting in considerable emotional distress.
Some providers may wish to delay surgery until skeletal or sex-
ual maturation is complete due to possibility of additional
growth and potential need for reoperation. However, the bene-
fits of early surgical intervention may o set the risk of reopera-
tion, particularly in patients with severe gynecomastia or those
su ering from teasing, bullying, and considerable psychological
impairment due to the appearance of their chest. Early surgical
intervention may alleviate and prevent the exacerbation of psy-
chosocial symptoms into adulthood.
Management is highly dependent on the grade of gyneco-
mastia and the degree of glandular, adipose, and skin involve-
ment. Mild to moderate gynecomastia (grades I–II) can be
treated using less invasive techniques. In these instances, a suf-
ficient reduction in volume and contour can be achieved using
a combination of simple excision through a periareolar incision,
ultrasound-assisted liposuction, or standard suction-assisted
lipectomy to reduce the potential for scarring (Fig. 26.2).
Extremely mild cases limited to the NAC may require only sim-
ple excision and can be performed in the clinic. In cases marked
predominately by excessive glandular tissue (grades Ib and IIb),
some have reported that ultrasound-assisted liposuction may
be advantageous over standard suction-assisted lipectomy. At
lower energy settings, ultrasound-assisted liposuction e ec-
tively removes adipose tissue while sparing higher density
structures; however, higher settings can target dense fibro-
glandular tissue.
A combination of subcutaneous mastectomy to remove gland
using a periareolar incision, mastopexy to elevate and resize
the NAC, and liposuction is employed in moderate to severe
cases of gynecomastia (Fig. 26.3). Most commonly, either a
concentric periareolar approach or an inferior pedicle and
inframammary or Wise- pattern incision are used. In some
severe cases, a complete mastectomy with free-nipple grafting
can also be used. A compression vest and drains may be used
for a short postoperative period. Mild to moderate discomfort
may persist for up to 5 days following surgery and can be
managed using over-the-counter and prescription analgesics.
The patient may remove dressings and shower after the first
o ce visit, leaving the steri-strips in place to self-detach.
Patients should stay out of school or work for roughly 1 week,
and exercise and heavy lifting should be avoided for the first 4
to 6 weeks following surgery, after which full activity can be
resumed.
Fig. 26.2 (a,b) A 16-year-old with Grade II
adolescent gynecomastia. (c,d) One year follow-
ing suction lipectomy, and transareolar simple
mastectomies.
Gynecomastia
261

26.5 Complications
Complication type and severity following surgical correction of
gynecomastia largely depend on treatment type. Patients
undergoing liposuction for grade I gynecomastia are more likely
to have fewer and less serious complications than a patient
undergoing mastectomy for grade IV gynecomastia. Periopera-
tive complications include those inherent in most procedures
performed in the operating room. Complications are typically
less prevalent and serious when surgical intervention is per-
formed by a plastic surgeon.
Early postoperative complications are typically minor and
more common in large volume resections. The most common
early complications are seroma and hematoma, which can be
managed with evacuation and drains as needed. Postoperative
infection is exceedingly rare in periareolar incisions and can be
treated using oral antibiotics.
Keloid and hypertrophic scar formation may occur, particu-
larly in patients undergoing large resections via a long infra-
mammary incision. Following scar maturation, scar revisions
can be performed in the clinic or operating room. Corticosteroid
injections can be employed in the clinic setting to decrease the
contour of existing keloids, and minim ize pain and pruritic
symptoms.
Long-term complications may include asymmetry and con-
tour irregularities, particularly following liposuction, lipectomy,
and large resections. An under-resection of peripheral tissue
can result in considerable deformation, while an over-resection
of tissue near the NAC can result in insu cient projection and a
saucerlike deformity. Loose skin is to be expected following
large resections and may improve over the first year in patients
who are young, still growing, and have good skin quality.
Patients should be advised during the preoperative visit that
persistent lax skin may require correction in the future or
additional skin resection at the time of the primary operation.
Breast regrowth following surgical correction is unlikely to
occur in older patients or those with moderate to severe gyne-
comastia. However, younger patients who have not completed
puberty or patients with gynecomastia of an uncontrolled,
pathological origin may exhibit additional grow th of any
remaining glandular tissue following surgery.
26.6 Conclusion
Pubertal gynecomastia is a common finding among otherwise
healthy adolescent boys. True gynecomastia is marked by
the proliferation of glandular breast tissue of varying severity,
although excess adipose tissue is commonly present as well.
Most cases of idiopathic gynecomastia are self-resolving and
require only sympathetic reassurance. Proper workup is essential
in suspected drug-induced, or pathological, cases of gynecomas-
tia. Regardless of composition, cause, or severity, gynecomastia
can result in significant mental health and self-esteem deficits.
During clinic visits, the plastic surgeon should assess current
mental status and make referrals when necessary.
Surgical intervention may be warranted in cases of persis-
tent, severe, or distressing gynecomastia. Early surgical inter-
vention may alleviate and prevent the exacerbation of
psychosocial symptoms into adulthood. Surgical treatment is
largely dependent on the severity and grade of gynecomastia.
Mild gynecomastia of grades I or II may be managed using sim-
ple excision or liposuction performed in either the clinic or the
operating room. Treatment of moderate to severe gynecomastia
is more invasive and may necessitate the need for larger com-
posite resections. Complications, though typically minor, are
common and are more frequently associated with larger
resections.
Fig. 26.3 (a,b) A 17-year-old with Grade III
adolescent gynecomastia. (c,d) Three years fol-
lowing suction lipectomy, bilateral simple mas-
tectomies, and concentric mastopexies.
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262

26.7 Key Points
● Gynecomastia is the benign overgrowth of glandular breast
tissue in males. Breast hypertrophy is a common finding in
healthy adolescent boys and is mostly idiopathic and self-
resolving.
● Patients may su er from psychological and self-esteem defi-
cits due to their chest size.
● Gynecomastia is described using a graded scale of I to IV,
encompassing varying degrees of severity and glandular, adi-
pose, and skin involvement.
● A combination of mastectomy, mastopexy, liposuction, and
lipectomy can be employed to achieve a su cient reduction
in the size and contour of the breast mound while resizing
and repositioning the nipple areolar complex nipple areolar
complex (NAC).
● Satisfaction with surgery remains high among patients
despite relatively frequent minor postoperative
complications.
● Revision surgeries may be performed in instances of persis-
tent skin laxity, hypertrophic scar formation, and postoperati-
ve asymmetry.
Suggested Readings
Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008;
20(4):375–382
Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and ma-
nagement. Mayo Clin Proc. 2009; 84(11):1010–1015
Rohrich RJ, Ha RY, Kenkel JM, Adams WP , Jr. Classification and management
of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast
Reconstr Surg. 2003; 111(2):909–923, discussion 924–925
Rosen H, Webb ML, DiVasta AD, et al. Adolescent gynecomastia: not only an
obesity issue. Ann Plast Surg. 2010; 64(5):688–690
Ma NS, Ge ner ME. Gynecomastia in prepubertal and pubertal men. Curr
Opin Pediatr. 2008; 20(4):465–470
Nuzzi LC, Cerrato FE, Erickson CR, et al. Psychosocial impact of adolescent
gynecomastia: a prospective case-control study. Plast Reconstr Surg. 2013;
131(4):890–896
Karp NS. Gynecomastia. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP,
Gurtner GC, Spear SL, eds. Grabb and Smith’s Plastic Surgery. 7th ed. Philadel-
phia, PA: Lippincott Williams & Wilkins; 2014:615–619
Fischer S, Hirsch T, Hirche C, et al. Surgical treatment of primary gynecomas-
tia in children and adolescents. Pediatr Surg Int. 2014; 30(6):641–647
Braunstein GD. Management of gynecomastia. In: Post TW, ed. UpToDate.
Waltham, MA: UpToDate; 2015
Gynecomastia
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27 Breast Asymmetry
Laura C. Nuzzi and Brian I. Labow
Sum m ary
Breast asymmetry is not a formal diagnosis, but rather a term
that encompasses normal and abnormal variances in breast
size, shape, or position of idiopathic, congenital, or acquired
origin. Although breast asymmetry is exceedingly common dur-
ing adolescence, abnormal asymmetry that persists into late
adolescence and early adulthood has the potential to negatively
impact an adolescent’s quality of life, psychosocial well-being,
and self-esteem. A variety of hyperplastic and hypoplastic
breast conditions can result in asymmetry. Additionally, adoles-
cents may present with acquired breast asymmetry secondary
to benign masses, prior breast surgery, or trauma to the breast
bud or gland.
Breast asymmetry can be managed by non-surgical or surgi-
cal means depending on the severity of the di erence and level
of patient distress. As some degree of asymmetry is common
during thelarche, it is generally advisable to observe younger
adolescent patients until they are close to completing or have
completed skeletal growth. Breast prostheses or bra inserts may
be of particular benefit to younger patients who are distressed
by the uneven contour and size of their breasts given these
devices immediately improve appearance, can be adjusted
easily with growth, and can be worn during exercise and under
swimsuits. Abnormal, persistent, or psychologically distressing
asymmetry can be surgically corrected once the patient reaches
skeletal and emotional maturity. The plastic surgeon may
employ a combination of breast augmentation, mastopexy, and
reduction mammaplasty to improve symmetry and meet the
individual goals of the patient. Postoperative complications
vary by the type of surgical operation performed, though the
potential need for revisional procedures should be emphasized
preoperatively for this population.
Keywords: breast asymmetry, adolescent, breast augmentation,
mastopexy, reduction mammaplasty, abnormal asymmetry
27.1 Introduction
Breast asymmetry is exceedingly common during adolescence.
Thelarche is marked by glandular proliferation of varying rates
and may result in uneven-appearing breasts early in develop-
ment. Pubertal breast asymmetry typically improves or com-
pletely resolves as breast growth slows during late adolescence.
Mild breast di erences, however, may persist into adulthood
and is a normal finding on examination. Breast asymmetry is
not a formal diagnosis, but a catch-all term encompassing a
spectrum of normal and abnormal breast di erences of various
etiologies (Fig. 27.1; Box 27.1).
Box 27.1 Etiology of Adolescent Breast
Asymmetry
1. Pubertal
2. Hyperplastic breast condition
a) Macromastia
b) Virginal breast hypertrophy
3. Hypoplastic breast condition
a) Amazia
b) Amastia
c) Breast hypoplasia
d) Poland syndrome
e) Tuberous breast deformity
4. Acquired
a) Benign palpable masses
b) Malignant neoplasms
c) Prior breast surgery
d) Trauma
The burden of adolescent breast asymmetry is primarily psy-
chological. Mild to severe breast asymmetry can negatively
impact an adolescent’s quality of life, psychosocial well-being,
and self-esteem. Patients may report di culty finding bras
that properly fit each breast, embarrassment or teasing among
peers, and reluctance to wear fitted clothing and swimsuits that
highlight breast irregularities.
Nonsurgical management aims to immediately improve cosm-
esis and self-esteem through the use of prosthetic bra inserts
and custom bras. Surgery may be warranted in cases of distress-
ing or abnormal asymmetry that persists into late adolescence
or early adulthood. The type of surgical intervention is dictated
by the individual patient’s breast di erences and expectations.
The plastic surgeon may employ a combination of breast aug-
mentation, mastopexy, and reduction mammaplasty to achieve
symmetry and meet the individual goals of the patient.
27.2 Diagnosis
Breast asymmetry is not a formal diagnosis, but rather an
umbrella term describing normal and abnormal di erences
in breast size, shape, or position of idiopathic, congenital, or
acquired origin. Presentation and degree of severity can vary
widely; however, most adolescents with breast asymmetry will
exhibit normally developed breasts of unequal sizes, ranging
from less than one cup size di erence between breasts to that
of four or more cup sizes. Asymmetry is common, and an esti-
mated 90% of all women will experience some degree of breast
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264

Fig. 27.1 Asymmetry of varying severity and etiology. (a,b) A 16-year-old with mild to moderate breast asymmetry (250 mL, or two-cup-size
difference). (c,d) A 19-year-old with severe breast asymmetry (1,250 mL, or four-cup-size difference). (e,f) A 17-year-old with breast asymmetry
secondary to giant fibroadenoma excision 4 years prior (arrow points to well-healed incision). (Continued)
Breast Asymmetry
265

asymmetry over their lifetime. Most adolescent cases are idio-
pathic and the byproduct of normal glandular proliferation
during breast development. Onset of pubertal asymmetry is
common at thelarche (Tanner stage 2) and improves over the
course of breast maturation.
A variety of hyperplastic and hypoplastic breast conditions
may yield asymmetries in volume, shape, and position. Unilat-
eral macromastia or asymmetric bilateral macromastia will
result in one breast that is considerably hypertrophic and ptotic
relative to the contralateral breast. These patients may present
with musculoskeletal pain, bra strap grooving, breast striae, and
inframammary fold intertrigo. Formal “diagnosis” of unilateral
or asymmetric macromastia can be supported using the Schnur
Sliding Scale. Many insurers utilize this scale, which uses calcu-
lated body surface area to determine the breast resection mass
necessary for a reduction mammaplasty to be considered medi-
cally indicated.
Breast asymmetry secondary to a hypoplastic breast condi-
tion is less common and presents with varying degrees of uni-
lateral or bilateral breast insu ciency. Breast hypoplasia and
amazia are defined, respectively, by an insu ciency or com-
plete absence of breast tissue with intact pectoralis major
muscle and nipple areolar complex (NAC). Amastia, however, is
an extremely rare congenital anomaly marked by the absence
of both the breast gland and the NAC. Tuberous breast deform-
ity is a developmental anomaly resulting in a constricted breast,
a high inframammary fold, and pseudo-herniation of the breast
gland through the areola (Fig. 27.2). Ptosis, breast hypoplasia,
and skin insu ciency typically accompany moderate to severe
tuberous breast deformity. Poland syndrome is a rare congeni-
tal chest anomaly a ecting both males and females. Patients
will present with partial or complete unilateral absence of
the pectoralis major muscle, and commonly ipsilateral upper
extremity anomalies. Females may also exhibit bilateral or uni-
lateral breast hypoplasia or amazia along with a superiorly dis-
placed and hypoplastic NAC. The majority of patients with
Poland syndrome are diagnosed at birth, although extremely
subtle cases may not be diagnosed until adolescence.
Adolescents may also present with acquired breast asymmetry
secondary to benign masses (e.g., fibroadenoma, hemangioma,
and vascular malformation), prior breast surgery, or trauma to
the breast bud or gland. Presence of fibroadenoma should be
ruled out in patients presenting with breast pain or tenderness.
27.3 Nonoperative Management
As some degree of asymmetry is common during thelarche, it is
generally advisable to observe younger adolescent patients
over time for resolution or worsening of symptoms. Adolescent
asymmetry is largely idiopathic with considerable improve-
ment typically appreciated by Tanner Stage 4. Patients should
be monitored at least annually, and sympathetic reassurance
and counsel with respect to management should be provided
during these visits.
Fig. 27.2 A 15-year-old patient with mild asymmetry and severe
tuberous breast deformity.
Fig. 27.1 (Continued) (g) A 15-year-old with Poland syndrome, right-
sided amazia, and ipsilateral symbrachydactyly.
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266

The psychosocial impact of breast asymmetry must not be
ignored. Adolescents with varied diagnoses and degrees of
severity may su er diminished emotional well-being, self-
esteem, and social functioning. Patients may report teasing or
embarrassment among peers due to the appearance of their
chest. During clinic visits, the plastic surgeon should assess cur-
rent mental status, document worsening of symptoms, and
make referral for psychological management when necessary.
As breast asymmetry is associated with obesity, weight loss and
nutritional management should also be encouraged. Patients
should be advised, however, that weight loss alone will not alle-
viate the appearance of their breast asymmetry, particularly in
cases of unilateral or asymmetric macromastia with substantial
glandular involvement.
Although surgery should be deferred until skeletal and emo-
tional maturity is reached, nonsurgical intervention may help
o set the negative psychosocial impact of breast asymmetry.
Finding properly fitted bras and clothing may serve as a source
of stress for adolescents with asymmetry. The plastic surgeon
may wish to become familiarized with clothing stores that
provide seamstress services to join bra cups of di ering sizes to
create a single garment that properly fits each breast. Breast
prostheses or bra inserts may be of particular benefit to adoles-
cent patients who are distressed by the uneven contour
and size of their breasts. These devices immediately improve
cosmesis and many can be worn during exercise and under
swimsuits.
27.4 Operative Treatment
Abnormal, persistent, or psychologically distressing asymmetry
can be surgically corrected once the patient is skeletally and
emotionally mature. The majority of patients seeking surgical
intervention for idiopathic asymmetry or breast hypoplasia opt
for breast augmentation. Improved symmetry with the con-
tralateral breast can be achieved through unilateral or bilateral
implant placement, with or without mastopexy, and is largely
dependent on the individual needs of the patient.
Most patients with breast asymmetry secondary to a devel-
opmental or congenital anomaly will undergo surgery to cor-
rect deformations in breast shape and position to restore
symmetry. Severe hypoplasia, amazia, or Poland syndrome may
require a staged approach using tissue expansion to increase
the skin envelope prior to definitive implant placement.
Correction of tuberous breast deformity aims to release the
constricted base of the breast, lower the inframammary fold,
correct the herniated appearance of the NAC, and increase
breast volume and skin su ciency if necessary. This typically
requires a periareolar approach with removal of a concentric
ring of excess areolar skin, subglandular scoring, lowering the
inframammary fold, and a subglandular or subpectoral breast
implant ( Fig. 27.3). Treatment for severe tuberous breast
deformity may require tissue expansion prior to definitive
treatment. Mastopexy may be needed in cases of moderate
to severe ptosis to reposition the NAC above the inframam-
mary fold. Treatment of Poland syndrome requires a more
complex reconstruction, typically employing a latissim us
dorsi transfer transposed over the right chest wall to support
the placement of tissue expander or breast implant. Although
implant-only reconstructions can be used in mild cases, the
results are generally less satisfying in moderate to severe
cases. Autologous free-tissue transfer can also be performed
in cases where there is a larger-sized contralateral breast or
when the patient prefers to avoid an implant. If this is the
case, it is important to ensure the presence of adequate
recipient vessels preoperatively and establish a backup plan
Fig. 27.3 A 19-year-old with tuberous breast
deformity (a,b) preoperatively and (c,d) 1 year
following correction with areolar size reduction,
subglandular scoring, and subpectoral 325 mL,
smooth, round, saline implants.
Breast Asymmetry
267

in case they are hypoplastic or absent. Contralateral masto-
pexy may be performed to further improve symmetry
( Fig. 27.4).
In instances of unilateral macromastia or asymmetric bilat-
eral macromastia, either unilateral reduction mammaplasty or
bilateral asymmetric reduction can be performed ( Fig. 27.5).
Estimating volume di erences preoperatively can be facilitated
using sizers and appropriate full-coverage unpadded bras. In
some instances, a reduction on the larger side and a mastopexy
alone on the contralateral side may be su cient. A variety of
techniques exist for all of these options and all work well
(Fig. 27.6).
Fig. 27.4 A 20-year-old with Poland syndrome (a,
b) preoperatively and (c,d) 2 years following free
transverse rectus abdominis myocutaneous
(TRAM) flap reconstruction and 1 year after
contralateral mastopexy. Prior to free-tissue
transfer, tissue expansion was used to develop an
adequate skin envelope for the reconstructed
breast.
Fig. 27.5 An 18-year-old with moderate breast
asymmetry (a,b) preoperatively and (c,d) 1 year
following unilateral, right side vertical scar
reduction mammaplasty (380 g).
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268

27.5 Postoperative Management
The postoperative routine varies depending on the procedure
performed. In cases of unilateral or bilateral reduction/masto-
pexy procedures, the surgical site is often covered with steri-
strips, absorbent dressings, and a surgical support bra. At the
first postoperative visit, the dressing is removed and the surgi-
cal site checked. Typically, patients require 3 to 5 days of pre-
scription pain medication and are out of school or work for
roughly 1 week. Exercise and lifting should be avoided for the
first 6 weeks following surgery, after which full activity can be
resumed. Similarly, patients should use a supportive sports bra
and avoid a bra with an underwire for 6 weeks following reduc-
tion mammaplasty. The recovery following unilateral or bilat-
eral augmentation procedures is typically shorter in duration.
Appropriate supportive bras are used, and high-exertion or
high-impact activities, especially those involving the upper
extremities, are limited for at least several weeks. Given the
presence of the foreign body, attention to avoiding wound-heal-
ing problems and infection is paramount. Once in place,
implants should be monitored annually for potential problems
such as deflation, malposition, or abnormal contour.
27.6 Complications
Postoperative complications vary by the type of surgical proce-
dure performed. Early complications following breast augmen-
tation may include bleeding, infection, or implant exposure.
Severe cases of infection may necessitate removal of the
implant. Other implant-related complications include capsular
contracture, visible wrinkling or rippling, displacement, or fail-
ure requiring replacement. Secondary procedures may be
required as the patient ages. Additional views will be required
during mammography later in life as the implant can obscure
breast tissue. In rare instances, implant-associated lymphomas
have been reported and some federal recommendations have
been made for interval radiographic evaluation of the implant
over time.
An estimated 40 to 50% of patients undergoing reduction
mammaplasty will experience a complication. These complica-
tions are typically minor and occur during early wound healing.
Infection, bleeding, wound dehiscence, and seroma or hema-
toma requiring reoperation and evacuation are most commonly
reported. Nipple and fat necroses are exceedingly rare in the
healthy adolescent population.
Patients should be followed closely during the first postopera-
tive year to assess long-term complications. Diminished nipple
and breast sensation is normal during the early healing period
following any breast surgery. A subset of women, however, will
have partial or complete loss of breast and/or nipple sensation
that persists after the first postoperative year. Scarring and
keloid formation are common following large resections.
Some degree of asymmetry is to be expected following breast
surgery. Patients should be advised that although surgical inter-
vention aims to reduce the appearance of asymmetry, some
breast di erences may persist following surgery. Di erences in
breast size and position are common following implant place-
ment. Additionally, discrepancies in NAC size and position may
be appreciated after reduction mammaplasty and mastopexy.
Revisional procedures to correct postoperative asymmetry
should be addressed after the first year to allow swelling to
resolve and the breast and/or implant to settle.
Adolescents undergoing surgical intervention may require
future reoperation due to continued breast grow th. In some
instances, the augmented breast may outgrow the contralateral
breast, or the hyperplastic breast may continue to grow after
reduction. Although this is certainly possible and surgical inter-
vention should be delayed until breast maturation is achieved,
age should not be an absolute contraindication to treatment.
For many patients, the psychosocial benefits of early surgical
intervention far outweigh the risk of a repeat procedure later in
life.
Fig. 27.6 A 19-year-old with severe breast asym-
metry (a,b) preoperatively and (c,d) 8 years
following right Wise pattern reduction mamma-
plasty (1,500 g) and 7 years following left
augmentation mammaplasty with a submuscular
300 mL smooth, round gel implant.
Breast Asymmetry
269

Patients with breast asymmetry may also be at an increased
risk for future lactation di culty. Breast hypoplasia by defini-
tion may curtail milk volume due to breast gland insu ciency.
Surgical intervention may also diminish nipple sensitivity and
impede future latching and lactation. Although reduction mam-
maplasty largely spares neurovascular structures of the ductal
breast tissue, patients may need to supplement their milk sup-
ply. Furthermore, breast implant placement may hinder a wom-
an’s ability to lactate. Patients undergoing surgical intervention
should be counseled with respect to future lactation.
27.7 Conclusion
Most women will exhibit breast asymmetry during their life-
time. Breast asymmetry is not a formal diagnosis, but rather a
broad description encompassing both norm al and abnormal
di erences in breast size, shape, or position. Size and shape dif-
ferences are particularly prevalent during early breast matura-
tion. Most adolescent cases of breast asymmetry are due to
variable rates of breast gland proliferation during early puberty
and will improve or resolve completely without intervention.
Less commonly, asymmetry may be secondary to hyperplastic
and hypoplastic breast conditions of developmental or congeni-
tal origin.
Asymmetry of any severity can negatively a ect a patient’s
quality of life, self-esteem, and social functioning. Early inter-
vention, however, may alleviate and prevent the exacerbation
of psychosocial symptoms into adulthood. Young patients who
are concerned by the appearance of their breasts should be
encouraged to explore prostheses or bra inserts to improve the
appearance of their chest within clothing. Surgery may be war-
ranted in cases of abnormal asymmetry that persists into late
adolescence or early adulthood. A combination of breast aug-
mentation, reduction mammaplasty, mastopexy, and tissue
expansion can be employed to achieve symmetry with the con-
tralateral breast and meet the individual goals of the patient.
27.8 Key Points
● Breast asymmetry is a common finding in adolescent and
adult women.
● Breast asymmetry describes normal and abnormal di erences
in breast size, shape, and position.
● The majority of adolescent cases are idiopathic and self-
limiting.
● Less commonly, asymmetry may be secondary to hyperplastic
or hypoplastic breast conditions, benign or neoplastic masses,
trauma to the breast bud or gland, or prior breast surgery.
● Surgical treatment may be warranted for distressing, abnor-
mal, or persistent asymmetry, and can comprise a combina-
tion of breast augmentation, mastopexy, and reduction
mammaplasty.
Suggested Readings
Caouette-Laberge L, Bortoluzzi P. Correction of breast asymmetry in teen-
agers. In: Hall-Findley E, Evans G., eds. Aesthetic and Reconstructive Surgery
of the Breast. Philadelphia, PA: Saunders Elsevier; 2010:601–629
Chan W, Mathur B, Slade-Sharman D, Ramakrishnan V. Developmental breast
asymmetry. Breast J. 2011; 17(4):391–398
Kolker AR, Collins MS. Tuberous breast deformity: classification and treat-
ment strategy for improving consistency in aesthetic correction. Plast
Reconstr Surg. 2015; 135(1):73–86
Novaković M, Lukac M, Kozarski J, et al. Principles of surgical treatment of
congenital, developmental and acquired female breast asymmetries. Vojnosa-
nit Pregl. 2010; 67(4):313–320
Nuzzi LC, Cerrato FE, Webb ML, et al. Psychological impact of breast asymme-
try on adolescents: a prospective cohort study. Plast Reconstr Surg. 2014;
134(6):1116–1123
Rubinstein C. Breast asymmetries. In: Hall-Findley E, Evans G., eds. Aesthetic
and Reconstructive Surgery of the Breast. Philadelphia, PA: Saunders Elsevier;
2010:547–570
Slezak R, Sasiadek M. Poland’s syndrome [in Polish]. Pol Merkuriusz Lek.
2000; 9(50):568–571
Winocour S, Lemaine V. Hypoplastic breast anomalies in the female adoles-
cent breast. Semin Plast Surg. 2013; 27(1):42–48
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270

28 Anterior Trunk Disorders
Carolyn M. Pike and Brian I. Labow
Sum m ary
Disorders of the anterior trunk include congenital defects of the
abdominal or chest wall. Gastroschisis and omphalocele are the
two most common congenital abdominal wall defects. The
absence of a covering membrane around the herniated abdomi-
nal contents di erentiates gastroschisis from omphalocele, and
also may a ect timing of surgical management. Bladder exstro-
phy is a rare malformation of the infra-umbilical abdominal
wall that is easily recognizable at birth, but is rarely diagnosed
prenatally. Prune belly syndrome is characterized by hypoplas-
tic or absent anterior abdominal wall musculature leading to a
wrinkled appearance of the abdomen. Congenital chest wall
diagnoses include pectus excavatum and pectus carinatum. Pec-
tus excavatum is characterized by a concave appearance to the
anterior chest wall, while pectus carinatum presents as a pro-
trusion of the sternum and/or ribs with a depression along the
sides of the chest.
The goal of surgery for patients with gastroschisis and
omphalocele is to safely return the eviscerated bowel to the
peritoneal cavity and establish abdominal wall integrity. Surgi-
cal closure for gastroschisis and omphalocele can be achieved
via primary reduction, or delayed, staged closure. Treatment for
bladder exstrophy usually occurs in a staged manner to close
the bladder and abdominal wall. Plastic surgeons may be
involved in late corrections of abdominal scarring and, inci-
sional hernias or bulges. Although the majority of umbilical
hernias will close spontaneously, large defects or those that
persist to school age may require surgical repair. A variety of
non-operative, minim ally invasive and invasive modalities exist
to treat both pectus carinatum and excavatum.
Keywords: anterior trunk disorders, gastroschisis, omphalocele,
bladder exstrophy, Prune belly syndrome, pectus excavatum,
pectus carinatum, congenital
28.1 Introduction
Disorders of the anterior trunk constitute a wide array of con-
genital defects of the abdominal or chest wall. These disorders
range in severity and frequency and are typically managed by
pediatric surgeons. Plastic surgeons who treat children and
young adults can apply a host of reconstructive and aesthetic
techniques in the early as well as late management of these
conditions. As such, it is worthwhile for the plastic surgeon to
familiarize themselves with some of the more common anterior
trunk disorders.
Minor congenital abdominal wall defects are common. In par-
ticular, umbilical or inguinal hernias are frequently encoun-
tered. Gastroschisis and omphalocele are the most common
serious congenital abdominal wall defects, and are frequently
diagnosed antenatally. Gastroschisis is characterized by free
herniation of the abdominal viscera. There is no membrane cov-
ering the herniated abdominal contents, which di erentiates
gastroschisis from omphalocele. This condition has doubled
in incidence over the past decade for unclear reasons, with
approximately 2,000 new cases per year in the United States.
Omphalocele is a related condition also characterized by evis-
ceration of intra-abdominal organs. However, these viscera are
contained in a sac that protects the viscera, minimizes neonatal
fluid losses, and a ords substantial time to repair unlike gastro-
schisis (Fig. 28.1). Unlike the periumbilical defects above,
bladder exstrophy is a rare malformation of the infraumbilical
abdominal wall. Incomplete closure of the bladder, protrusion
of the posterior bladder wall through the lower abdominal
wall, epispadias, as well as alterations in the pelvic bones
and muscles necessitate early acute multidisciplinary care. Late
defects of the abdominal wall such as bulges, hernias, and
depressed scars are common. In addition, complex genitouri-
nary defects may also require multiple complex reconstructive
procedures. Another very rare condition that a ects both the
abdominal wall and the urinary tract is prune belly syndrome.
In this condition, the anterior abdominal wall musculature is
hypoplastic or absent, leading to a wrinkled appearance of the
abdomen (Fig. 28.2). In addition to the marked skin redun-
dancy and distortion of the trunk, severe urological abnormal-
ities and cryptorchidism frequently occur.
The range of a congenital chest wall diagnoses is smaller, but
some diagnoses are common as well. Pectus excavatum, for
example, may occur in 1/150 to 1/1,000 live births and is fami-
lial in 40% of cases. It is characterized by a concave appearance
to the anterior chest wall and is the most common chest wall
abnormality. The depression may be mild or quite severe,
impacting cardiac and pulmonary function (Fig. 28.3). In
addition, it can be present at birth or manifest during adoles-
cence. In contrast, pectus carinatum presents as a protrusion of
the sternum and/or ribs with a depression along the sides of
the chest (Fig. 28.4). Though not as common as pectus excava-
tum (occurring only 1/10th as often), it accounts for roughly 5
to 7% of chest wall anomalies overall. The condition is usually
isolated and nonsyndromic though pectus carinatum can be
Fig. 28.1 A 1-month-old male with large omphalocele. Note the well-
epithelialized sac containing the viscera.
Anterior Trunk Disorders
271

seen in patients with Marfan, Ehlers–Danlos, Noonan, and
Turner syndromes as well as others.
28.2 Diagnosis
Most diagnoses of the anterior trunk can be made following his-
tory and physical examination. Radiological evaluation may also
be extremely useful early or even later in life. Severe conditions
can also be recognized by prenatal ultrasound and appropriate
plans for postdelivery management made in advance. In many
of these conditions, concurrent severe comorbidities may exist
and must be sought out.
The prenatal diagnosis of gastroschisis is possible from the
end of the first trimester, after the physiological closure of the
abdominal wall around 10 weeks of gestation. The ultrasound
detects loops of bowel outside of the abdominal cavity, herni-
ated through a small paraumbilical wall defect and floating
in the amniotic fluid without any covering membrane. The
absence of this covering allows one to di erentiate gastroschisis
from omphalocele. Present techniques can predict complicated
gastroschisis and outcomes associated with degree of intra-
abdominal dilatation. A raised maternal alpha fetoprotein is
also indicative of gastroschisis. Gastroschisis is not associated
with chromosomal anomalies and generally occurs as an iso-
lated anomaly. An omphalocele can also be diagnosed by ultra-
sound during the late first trimester, but is more commonly
confirmed during the 18-week ultrasound. In some cases, an
elevated maternal alpha fetoprotein level may also be identi-
fied, though less commonly than in gastroschisis. Associated
anomalies are common and include cardiac, renal, skeletal, and
neural tube abnormalities. Omphaloceles are often associated
with chromosomal anomalies (such as Trisomy 13, 18, and 21)
as well as other syndromes such as Beckwith–Wiedemann.
Fig. 28.2 A 13-year-old male with prune belly syndrome. Note
urostomy in the right lower quadrant and scarring from prior urological
procedures.
Fig. 28.3 A 16-year-old female with mild pectus excavatum.
Fig. 28.4 A 14-year-old male with mild pectus carinatum.
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272

Umbilical hernias occur when the umbilical ring is not fully
closed and can be diagnosed upon physical examination. Rarely
is any imaging required. A protruding soft-tissue mass and a
palpable defect in the fascia is diagnostic. Similarly, pediatric
inguinal hernias are diagnosed clinically with a visible soft-
tissue bulge in the inguinal region. In boys, ipsilateral scrotal
swelling may be secondary to a hernia or a hydrocele. Ultraso-
nography may be used to di erentiate between the two.
Bladder exstrophy is easily recognizable at birth, but is rarely
diagnosed prenatally. The prenatal diagnosis consists of a non-
visible fetal bladder and low insertion of the umbilical cord.
Prune belly syndrom e can be diagnosed through a prenatal
ultrasound, although diagnosis is usually made shortly after
birth. It occurs most often in male infants. The ultrasound diag-
nosis in early gestation requires the identification of a megacyst
(distended bladder) and oligohydramnios. Undescended testes
and urinary tract anomalies are often noted postnatally on
physical examination and imaging.
The pectus excavatum and carinatum deformities are easily
visualized on physical examination. In some, the deformity may
be present early in life, whereas in others it will manifest during
adolescent growth. Symptoms may include exercise intolerance,
decreased endurance, pain, body image issues, and dyspnea. In
symptomatic individuals, computed tomography (CT) scans
may be warranted to determine the severity of the pectus
defect and potentially assist in reconstructive planning. In cases
of pectus excavatum, cardiac and pulmonary compression may
be documented in conjunction with functional tests such as an
echocardiogram or pulmonary function testing. Patients with
pectus carinatum manifest a sternal protrusion with a depres-
sion along the sides of the chest. Most are male and present dur-
ing adolescence. Associated symptoms including chest wall pain,
frequent injuries, body image issues, and scoliosis should be
sought. Displacement of the thoracic musculature can interfere
with breathing, and 10% of patients experience exercise intoler-
ance. In symptomatic patients, a chest CT scan in conjunction
with pulmonary function testing can document severity.
28.3 Nonoperative Treatment
Many congenital defects of the anterior trunk may benefit by
nonoperative treatment either alone or in combination with
subsequent operative treatment. Although both gastroschisis
and omphalocele ultimately require surgical treatment, nonsur-
gical prenatal and neonatal care is equally essential in the ma-
nagement of these patients. In particular, body temperature
and intravascular volume need to be maintained. In addition to
intensive neonatal care, appropriate positioning and dressing
applications are essential to avoid kinking of the mesentery or
viscera to minimize the risk of ischemic injury.
Unless incarcerated or producing systemic symptoms, umbil-
ical and inguinal hernias do not require urgent surgical inter-
vention. In the case of umbilical hernias, if the defect is small
(<1 or 2 cm), 90% close within 3 years and some sources state
85% of all umbilical hernias, regardless of size, will close with-
out surgical treatment. In contrast, inguinal hernias do not
spontaneously heal and should be repaired operatively.
Patients with bladder exstrophy and those with prune belly
syndrome will present with both medical and surgical needs.
Just as with omphalocele and gastroschisis, neonatal as well as
intensive ongoing medical care is essential for these patients
early in life.
The majority of patients with pectus deformities are mini-
mally symptomatic or asymptomatic. In many cases, support
and reassurance may be all that is required. In the case of pec-
tus carinatum, there have been reports of bracing being used to
help diminish the prominence of the sternum.
28.4 Operative Treatment
28.4.1 Gastroschisis
The goal of surgery is to safely return the eviscerated bowel to
the peritoneal cavity and establish integrity to the abdominal
wall. The absence of any protective membrane over the bowel
as in omphalocele mandates urgent coverage and vigilant fluid
and temperature maintenance for the neonate. The degree of
visceroperitoneal disproportion will determine whether the
reduction can be performed primarily or in a staged manner.
Unless the defect is very small, a Silastic “silo” or cone is sewn
to the periphery of the fascial defect and sequential daily com-
pression is used to reduce the viscera progressively over time.
As the viscera are reduced, ventilation, intra-abdominal pres-
sure, and venous return will all be a ected. It is vital to monitor
these parameters as staged reduction occurs to avoid major
morbidity and mortality. If the defect is so large or the patient’s
physiology so marginal, direct fascial repair may not be possible
even with a staged approach over days. The pediatric plastic
surgeon may be of assistance utilizing abdominal reconstruc-
tive modalities such as biologic or prosthetic mesh, flap cover-
age, or component separation to achieve temporary closure.
Once the child has aged, secondary reconstruction by the plas-
tic surgeon can often improve both the appearance and the
function of the abdominal wall.
28.4.2 Omphalocele
The treatment goals and risks for patients with omphalocele are
similar to those with gastroschisis. However, there are some
very important di erences in timing that need to be empha-
sized. The presence of a membrane over the herniated viscera is
protective and thus allows for a considerably longer timeline for
reduction. In fact, successful treatment of large omphaloceles
has been extended over years. Thus, it is paramount to preserve
the integrity of the omphalocele sac, which will epithelialize
over a couple of weeks. If the defect is small or the degree of
visceroperitoneal disproportion is minimal, early closure can
certainly be achieved. However, the presence of medical comor-
bidities, especially cardiac anomalies, must be accounted for
along with the potential sequelae discussed earlier. The availabil-
ity of additional time for closure allows the reconstructive sur-
geon the option for tissue expansion in addition to the other
treatment modalities discussed earlier (Fig. 28.5). Subcutane-
ous, submuscular, as well as intraperitoneal tissue expansion
have all been reported in successful omphalocele closure.
28.4.3 Hernia
Although the majority of umbilical hernias will close spontane-
ously, large defects or those that persist to school age may
Anterior Trunk Disorders
273

require surgical repair (Fig. 28.6). Most repairs will be man-
aged by the pediatric surgeon. However, those with significant
skin excess or umbilical distortion may be referred for plastic
surgical assistance. Inguinal hernias invariably required surgical
repair. Fortunately, recurrence rates are low, and the procedure
is typically well tolerated. It is unusual for plastic surgical tech-
niques to be required for these defects.
28.4.4 Bladder exstrophy
Cloacal or bladder exstrophy requires considerable multispeci-
alty surgical care and medical management. Treatment usually
occurs in a staged manner to close the bladder and abdominal
wall as well as repair the bladder neck, and ultimately the epis-
padias. Although plastic surgeons are rarely involved early in
the patient’s life, late corrections of abdominal scarring, inci-
sional hernias, or bulges can substantially improve these
patients’ quality of life later on. Furthermore, genitourinary
complications such as urinary incontinence from incomplete
bladder neck closure or genital deformities can also be
addressed with plastic surgical techniques to assist the pedia-
tric urologist.
28.4.5 Prune Belly Syndrome
Patients with prune belly syndrome typically demonstrate
some degree of abdominal distension and skin wrinkling secon-
dary to the aberrant and underdeveloped abdominal muscula-
ture. Although renal and genitourinary issues predominate
early in life, adolescents and young adult patients may benefit
from abdominal wall reconstruction to advance the well-inner-
vated and well-vascularized peripheral muscle layers centrally
along with excision or plication of the deficient central muscle
and fascial tissues. This can be approached as for an abdomino-
plasty, and excision of redundant skin can also be performed at
the same time. A variety of techniques have been reported in
the plastic surgical literature.
28.4.6 Pectus Excavatum and Pectus
Carinatum
Surgical treatment of pectus deformities can be used to address
functional as well as aesthetic concerns. Historically, pediatric
surgeons have used two surgical techniques to address pectus
excavatum deformities, although newer alternative modalities
have certainly been described. The Ravitch procedure intro-
duced in the mid-20th century is an open procedure in which
the abnormal rib cartilage is resected while preserving the peri-
chondrium. The sternum is repositioned and held in place with
a plate until the cartilage has reformed. The Nuss procedure is a
minimally invasive alternative in which a metallic bar in intro-
duced intrathoracically via two small incisions. The bar is then
rotated into position adopting a convex posture to reposition
the costal cartilages and sternum. The bar is typically removed
2 to 5 years later. Patients without symptoms referable to the
deformity or those who simply wish to improve the appearance
of their chest may be referred to a plastic surgeon. A variety of
fill options including structural fat grafting and custom-made
implants have been described.
Pectus carinatum is usually corrected during adolescence or
late childhood. Although bracing options exist, a great deal of
compliance and dedication is required to complete therapy. For
those patients who fail bracing, similar surgical options (e.g.,
modified Nuss or Ravitch procedure) to pectus excavatum can be
employed. Camouflage options such as breast or chest augmen-
tation also exist for carinatum patients as well. In general, out-
comes for surgical treatment of both pectus deformities range
from good to excellent, with postoperative improvement noted
in exercise tolerance, quality of life, and body image perception.
28.5 Complications
Surgical complications following treatment of anterior trunk
deformities range from minor to major, and reflect the type of
surgical procedure performed. Major complications following
an excessively tight or rapid gastroschisis or omphalocele clo-
sure include abdominal compartment syndrome, necrotizing
enterocolitis, sepsis, renal failure, cardiopulmonary failure, and
enterocutaneous fistula. Late complications include hernias,
bulges, and hypertrophic or depressed scars. Complications fol-
lowing umbilical or inguinal hernia repair are infrequent and
generally minor. Although spermatic cord or bowel injuries can
Fig. 28.5 An 8-year-old female with large, persistent umbilical hernia.
Trunk and Lower Extremity
274

occur after inguinal hernia repairs, these major complications
are very rare. Either umbilical or inguinal hernias can recur and
may require additional surgery. Exstrophy patients may su er
similar complications to patients with other abdominal wall
defects following early surgical procedures. Long-term compli-
cations such as recurrent urinary tract infections, incontinence,
sexual dysfunction, and pain are also common. The surgical
complications following surgery for prune belly syndrome are
frequent due to the high rate of renal and pulmonary dysfunc-
tion and are similar to risks for abdominoplasty, such as
seroma, hematoma, dehiscence, and tissue loss.
Surgical complications following pectus repair also range
from minor to major depending on procedure type. Potential
complications in the management of pectus excavatum include
recurrence, floating sternum, breast hypoplasia, postoperative
pain (more common with Ravitch procedure), and implant
migration/extrusion with custom implants. Complications in
the treatment of pectus carinatum are similar to that of pectus
excavatum and include treatment failure in the case of bracing
or recurrence if a conservative resection is performed or the
support bar is removed prematurely.
28.6 Conclusion
Defects of the anterior trunk are common and encompass a
wide range of diagnoses. Although major defects such as
gastroschisis are rare, the incidence may be increasing. Most
major defects are now diagnosed antenatally and allow for ad-
equate time to prepare the parents and medical and surgical
teams in advance of delivery. Minor defects such as hernias or
mild pectus deformities are far more common and diagnosed
postnatally or later in childhood during physical examination.
For some diagnoses, nonsurgical or minimally invasive options
exist. In others, nonsurgical techniques can facilitate subse-
quent operative procedures. The reconstructive background of
the plastic surgeon allows for a unique role in both the acute
and late management of these conditions. For example, famili-
arity with fascial substitutes, component separation, and tissue
expansion can facilitate closure of large abdominal wall defects.
Similarly, application of aesthetic principles to patients who
have undergone exstrophy correction earlier in life or who have
prune belly syndrome can similarly improve self-esteem and
quality of life. Although involvement varies from center to cen-
ter, there are probably many patients with anterior trunk disor-
ders that could benefit from plastic surgical evaluation and
treatment who are not a orded the opportunity to do so.
28.7 Key Points
● Gastroschisis and omphalocele are the most frequent major
congenital abdominal wall defects. They di er in terms of ur-
gency to achieve closure and potential comorbidities.
Fig. 28.6 (a) A 9-month-old female with large
omphalocele treated with component separation
to allow for fascial closure. (b) Onlay acellular
dermal matrix over suture line. (c) Closure and
umbilicoplasty. (d) One-year follow-up.
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● For larger abdominal wall defects, biological or prosthetic
mesh, component separation, and tissue expansion may be
required.
● Plastic surgeons can o er patients with prune belly syndrome
and bladder exstrophy improved quality of life with secon-
dary reconstructive procedures later in adolescence or young
adulthood.
● Pectus excavatum and pectus carinatum are two common
chest wall deformities that may alter cardiopulmonary physi-
ology or may simply be an aesthetic concern. Avariety of non-
operative, minimally invasive, and invasive modalities exist to
treat both anomalies.
Suggested Readings
Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis, newborn ma-
nagement, and long-term outcomes. Semin Pediatr Surg. 2014; 23(5):283–
290
David AL, Tan A, Curry J. Gastroschisis: sonographic diagnosis, associations,
management and outcome. Prenat Diagn. 2008; 28(7):633–644
Kruit AS, Al-Ani SA, Jester I, Jester A. Multilayered flap technique: a method
for delayed closure of giant omphalocele. Ann Plast Surg. 2016; 76(6):680–
683
Tonni G, Ida V, Alessandro V, Bonasoni MP. Prune-belly syndrome: case series
and review of the literature regarding early prenatal diagnosis, epidemiology,
genetic factors, treatment, and prognosis. Fetal Pediatr Pathol. 2013; 31
(1):13–24
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29 Posterior Trunk Disorders
Arin K. Greene
Sum m ary
Posterior trunk disorders can be congenital (e.g. myelomenin-
goceles) or acquired (e.g. pressure ulcers), and frequently
require the expertise of plastic surgeons. Soft-tissue reconstruc-
tion is often required for wounds over the spine. Typically these
defects are closed with local tissue; grafts and free-tissue trans-
fer rarely are necessary.
Diagnosis of posterior trunk disorders is principally made by
history and physical examination. Management is influenced
by the depth of the wound, exposure of dura, infection, wound
size and location, presence of hardware, duration of the wound,
sensation and ambulatory status of the patient. The underlying
cause of the wound must be addressed before considering oper-
ative interventions. For instance, pressure ulcers typically heal
without operative intervention once the excessive pressure has
been eliminated.
Myelomeningocele repair usually involves neurosurgical in-
tervention in the first two days of life. Once the dura is closed, a
plastic surgeon may be required to provide soft-tissue coverage
for large defects. The reconstruction occurs in two planes: flaps
over the dural repair, and skin closure. Regional muscles, perfo-
rator flaps, skin grafts, and skin flaps are all potential options.
The first line of management of pressure ulcers in the pedia-
tric population involves periodic weight shifting, and specialized
wheel-chair cushions and beds for non-ambulatory patients. It is
important to investigate the cause of the wound and to elimi-
nate the etiology. Whilst conservative therapy is the mainstay of
treatment, operative closure is sometimes required. Other poste-
rior trunk disorders, such as wounds over the spine and trau-
matic soft-tissue defects, are also managed by plastic surgeons.
Keywords: posterior trunk disorder, myelomeningocele, pres-
sure ulcer, soft-tissue, reconstruction, spine
29.1 Introduction
Posterior trunk disorders can be congenital or acquired. The
most common malformation plastic surgeons are asked to man-
age is myelomeningocele. The most frequent acquired defect is
a pressure ulcer. Plastic surgeons often are asked to reconstruct
soft tissue for wounds over the spine. Generally, posterior trunk
defects are able to be closed using local tissue; grafts and free-
tissue transfer rarely are necessary.
29.2 Diagnosis
Diagnosis of posterior trunk disorders is made by history and
physical examination. Imaging and histopathology are rarely
indicated. Variables that will dictate treatment include the fol-
lowing: (1) depth of wound, (2) exposure of dura, (3) infection,
(4) wound size and location, (5) presence of hardware, (6) dura-
tion of the wound, and (7) sensation and ambulatory status of
the patient. If a wound has been present for at least 6 weeks,
then it is chronic and likely has not healed because of infection,
bacterial colonization of hardware, or pressure. The underlying
cause of the wound must be addressed before considering oper-
ative interventions.
29.3 Nonoperative Treatment
The surgeon managing a posterior trunk disorder should begin
considering reconstructive options as low on the reconstructive
ladder as possible. Pressure ulcers typically heal without opera-
tive intervention once the excessive pressure has been elimi-
nated. Superficial wounds can be allowed to heal secondarily.
Before considering operative intervention, the benefits of the
procedure must outweigh its risks.
29.4 Operative Treatment
29.4.1 Myelomeningocele
Myelomeningocele is the most common neural tube defect
a ecting approximately 1/3,000 children. The spinal cord is
exposed due to a cleft in the vertebral column and overlying
soft tissue. The repair is usually performed on the first or sec-
ond day of life to prevent cord desiccation and meningitis. After
the neurosurgeon detethers the spinal cord, infolds the placode,
and closes the dura, he/she may ask for a plastic surgeon to pro-
vide soft-tissue coverage if the defect is large. Several methods
have been described to reconstruct tissue over the dural repair:
regional muscles (latissimus dorsi, gluteus maximus), perfora-
tor flaps, skin grafts, and skin flaps (bilobed, bipedicle, rhom-
boid, rotation, V-Yadvancement).
I believe the best method to manage a myelomeningocele is to
reconstruct the area in two planes: (1) flaps over the dural repair
and (2) skin closure (Box 29.1). First, I use turnover paraspinous
fascial flaps to cover the dural repair (Fig. 29.1 and Fig. 29.2).
The flaps are elevated laterally to medially, turned over, and
sutured in the midline with interrupted 4–0 vicryl. Hydrodissec-
tion with local anesthetic lifts the fascia o the underlying
muscle facilitating the dissection. The paraspinous fascia pro-
vides a strong, tension-free, vascularized layer over the dural
repair. The thick tissue reinforces the dural incision line to
reduce the risk of cerebrospinal fluid leak. The fascial flaps sepa-
rate the dural and skin closure to reduce the risk of cerebrospinal
fluid contact with the integument and meningitis.
Box 29.1 Principles of Extradural Myelomenin-
gocele Reconstruction
1. Paraspinal turnover fascial flaps
a) Cover the dura and decrease cerebrospinal fluid leak
b) Separate dural repair from skin closure
c) Avoid gluteal/latissimus flaps, which can defunctionalize
a neurologically compromised patient
2. Linear midline skin closure
a) Reduces complications
b) Facilitates reoperations for tethered cord and scoliosis
Posterior Trunk Disorders
277

Fig. 29.1 Extradural myelomeningocele recon-
struction. (a) Fascia is incised laterally and
elevated medially over the underlying muscles.
(b) The turnover fascial flaps are sutured together
in the midline. (Adapted from Patel KB, Taghinia
AH, Proctor MR, Warf BC, Greene AK. Extradural
myelomeningocele reconstruction using local
turnover fascial flaps and midline linear skin
closure. J Plast Reconstr Aesthet Surg
2012;65:1569–1572.)
Fig. 29.2 A 1-day-old male with a 6 × 5 cm2 myelomeningocele. (a) Preoperative appearance. (b) Lateral incision marked to incise the paraspinous
muscle fascia. (c) Bilateral turnover fascial flaps raised. (d) Flaps sutured together over dura. (e) Skin defect closed linearly with drains after widely
undermining skin flaps. (f) Following suture removal 6 weeks postoperatively.
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278

This technique does not include muscle dissection and thus will
not worsen the functional deficit in a neurologically compro-
mised patient. The patient’s ambulatory status is related to the
level of spinal involvement. Ninety-five percent of children with
L5 or sacral myelomeningocele are able to ambulate moderate
distances (community ambulators). Patients with defects at L3
or above are only able to ambulate short distances (nonfunc-
tional ambulators). Sixty percent of patients with myelomenin-
goceles will be community ambulators, 15% nonfunctional
ambulators, and 25% are nonambulatory. Paraspinous turnover
fascial flaps obviate the need to use major muscle flaps (e.g.,
gluteal, latissimus), which are more complicated to dissect and
have a greater risk of complications. Harvest of gluteal and/or
latissimus muscles also can further defunctionalize an infant
with a myelomeningocele. Use of gluteal muscle flaps in a
potential community ambulator may cause the child to become
a nonfunctional ambulator or nonambulatory. Harvest of latis-
simus muscle will handicap a child’s ability to walk with
crutches and/or transfer from a wheelchair.
After providing deep soft-tissue coverage over the dural
repair with paraspinous fascia, the overlying skin is approxi-
mated. To approximate the integument, skin flaps are widely
undermined above the muscle fascia, advanced medially, and
sutured vertically in the midline over two drains with inter-
rupted 4–0 vicryl and 4–0 nylon suture. If large defects are
closed with tension, prone positioning is prescribed for a mini-
mum of 2 weeks postoperatively and the nylon sutures are
maintained for at least 4 weeks.
Skin closure in the midline is important for myelomeningo-
cele repair because patients often require additional operations
involving the posterior trunk. Secondary procedures for cord
tethering or spinal fusion for scoliosis occur in one-half of
patients. I avoid the use of bilobed, bipedicle, rhomboid, rota-
tion, or V-Y advancement flaps to minimize posterior trunk
scarring and complications ( Fig. 29.3). The vertical scar facili-
tates exposure for secondary spinal procedures and minimizes
the risk of skin necrosis from multiple posterior trunk incisions.
Wide skin undermining will achieve a linear, midline closure
without breakdown for even the largest defects. If the incision
line separates, it will heal secondarily without consequence;
the risk of meningitis is small because fascial flaps separate the
integument from the dura.
29.4.2 Pressure Ulcer
Sacral and ischial pressure ulcers occur in children who are
insensate (usually from myelomeningocele) or who have signif-
icant developmental delay and are nonambulatory. Pressure
ulcers in the pediatric population are managed similarly to
adults. Patients/providers are instructed to shift their weight
every 2 hours and are prescribed wheelchair cushions and beds
that reduce the risk of pressure ulcers.
Initial management of a pressure ulcer is to investigate what
caused the wound and to eliminate the etiology. Often, a change
in a cushion, new wheelchair, or a recent hospitalization cause
the skin breakdown. Full-thickness wounds are managed con-
servatively with dressing changes; necrotic tissue is sharply
debrided. A wristwatch set to alarm every 2 hours will remind
the patient/provider to shift the patient’s weight. Almost all
wounds will heal with local wound care and elimination of
pressure.
Exposed bone (stage 4) does not equate with osteomyelitis,
which is very rare. Patients with large wounds have increased
inflammatory markers. Magnetic resonance imaging (MRI) is
not a useful modality for diagnosis of osteomyelitis and will
show inflammatory changes because of the overlying wound.
Definitive diagnosis of osteomyelitis requires bone biopsy.
Wounds will contract and close over exposed bone. A vacuum-
assisted wound closure device may speed the healing of pres-
sure ulcers and is an easier dressing regimen compared to
gauze. Before placing a vacuum-assisted device, the area must
be clean of necrotic tissue.
If a wound does not improve after several weeks, then the
underlying pressure has not been adequately addressed. Closing
the wound operatively will fail if the patient/provider has not
eliminated pressure. Often, patients want a “quick-fix” and
operative closure of the wound. However, they must be edu-
cated that if they do not eliminate pressure the defect will recur
Fig. 29.3 Myelomeningocele repaired at an outside hospital with V-Y flaps. (a) Preoperative appearance. (b) Following closure of the soft-tissue defect.
(c) Skin necrosis of flaps. (d) Full-thickness skin loss.
Posterior Trunk Disorders
279

following any procedure. Large wounds that have taken a long
time to heal can develop an epithelialized sinus tract. This is an
indication to provide operative closure. The tract is painted
with methylene blue and then excised. Local muscle is approxi-
mated to eliminate dead space and skin is advanced and closed
linearly. Complicated flaps are not required.
29.4.3 Coverage of Spinal Wounds
Wounds over the midline spine usually result from incision line
dehiscence following a neurosurgical or orthopaedic procedure.
Principles of repair are the same as for myelomeningocele. If
the dura is exposed, it is best to turnover paraspinal fascial flaps
prior to closure of the integument; this usually occurs if the
wound follows cord detethering. If the wound only involves
the skin, then the integument can be approximated linearly
(Fig. 29.4). Occasionally titanium hardware is exposed from a
spinal fusion for scoliosis. If this occurs, then gluteal and/or lat-
issimus muscle flaps may be required to provide additional soft
tissue to cover the hardware to prevent exposure (Fig. 29.5).
In some cases, it is best to temporarily remove spinal hardware,
obtain definitive wound closure, and then reapply the hardware
under stable soft tissue.
Skin defects following wound dehiscence usually can be
closed linearly with delayed primary closure, especially because
there is no skin loss. The posterior trunk is a favorable location
to allow tissues to heal secondarily. Delayed primary closure
can be performed easily by widely undermining skin flaps and
suturing them in the midline. Similar to myelomeningocele,
repair of posterior trunk wounds should be done with a single
vertical line. Rotation/transposition of skin flaps or skin grafts
should be avoided because there is a higher risk of wound heal-
ing problems and di culty accessing the spine if additional
procedures are necessary in the future.
The posterior trunk is at higher risk for wound dehiscence
because (1) the patient is lying on the incision line and (2) there
is tension on the sutures when the patient changes position.
Large cutaneous sutures should be placed and not removed
before 4 weeks, when the wound has 40% of its strength. Typi-
cally, the goal of the reconstructive procedure is to obtain a
healed wound; suture marks are a secondary concern.
29.4.4 Trauma
The posterior trunk is a favorable location to reconstruct trau-
matic soft-tissue defects because (1) large areas can be allowed
to heal secondarily without the risk of morbidity from contrac-
tion, (2) significant local muscle flaps are available, and (3)
skin redundancy/elasticity allows wide undermining to close
wounds. Generally, patients should be managed low on the
reconstructive ladder; skin grafts and complicated procedures
should be avoided if possible ( Fig. 29.6).
29.5 Complications
The most common complication following posterior trunk
wound closure is dehiscence of the incision line. When patients
are supine, pressure on the incision line can cause separation of
the wound edges. In addition, bending or rising from the supine
position applies tension to the sutures. Consequently, large
interrupted sutures should be placed and not be removed until
adequate scar strength has been achieved. If wide skin under-
mining has been performed causing ischemic flaps (e.g., myelo-
meningocele repair), then the patient is placed in the prone or
lateral position for at least 2 weeks postoperatively. Wound
dehiscence can also be minimized by placing drains under
widely undermined skin. The drains help reduce the presence
Fig. 29.4 Chronic wound following incision and
drainage of an infected incision following an
orthopaedic spine procedure. (a) Preoperative
appearance. (b) Because the wound was super-
ficial, it was closed with delayed primary closure
after widely undermining the skin.
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280

Fig. 29.5 Nonambulatory patient with myelomeningocele who developed exposed hardware following a scoliosis procedure. (a) Preoperative
appearance. (b) Gluteal muscle mobilized. (c) Muscle coverage over hardware. (d) Linear midline closure after widely undermining skin flaps. (e) Three
months postoperatively.
Fig. 29.6 An adolescent female suffered a hematoma following a car accident several years prior to her presentation. She was unhappy with the
residual fullness of her right gluteal area. (a) Preoperative appearance with markings of normal gluteal creases on left and elliptical area of soft-tissue
overgrowth on right. (b) Intraoperative view of suction-assisted tissue removal. (c) Lipoaspirate. (d) Improved contour 3 months postoperatively.
Posterior Trunk Disorders
281

of blood under the skin flaps which can cause a “second hit”
and necrosis of the skin edges.
29.6 Conclusion
The posterior trunk is a favorable place for wounds because
there is a significant amount of local tissue that can be
mobilized to close defects. Also, scar contracture rarely inhibits
function. Usually wounds can be managed low on the recon-
structive ladder. Pressure ulcers and other skin defects can be
allowed to heal secondarily. If operative treatment is indicated,
wide skin undermining and linear closure can close most
defects. Paraspinous turnover fascial flaps can be used to cover
exposed dura, obviating the need to defunctionalize gluteal or
latissimus muscles. Because patients are lying on the incision
line, sutures should be maintained until adequate scar strength
has been achieved.
29.7 Key Points
● Most defects of the posterior trunk can be managed with local
tissues; skin grafts and free flaps are rarely needed.
● Turnover paraspinal fascial flaps should be used to cover
exposed dura prior to skin closure.
● Wounds over the spine are repaired with a single linear scar if
possible.
● Pressure ulcers will heal secondarily with the elimination of
pressure and rarely require operative closure.
Suggested Readings
Madden JW, Peacock EE , Jr. Studies on the biology of collagen during wound
healing. I. Rate of collagen synthesis and deposition in cutaneous wounds of
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2003; 30(1):1–12
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and regional flap closure in myelomeningocele repair: a 15-year review.
Childs Nerv Syst. 2010; 26(8):1091–1095
Patel KB, Taghinia AH, Proctor MR, Warf BC, Greene AK. Extradural myelome-
ningocele reconstruction using local turnover fascial flaps and midline linear
skin closure. J Plast Reconstr Aesthet Surg. 2012; 65(11):1569–1572
Levi B, Sugg KB, Lien SC, et al. Outcomes of tethered cord repair with a lay-
ered soft tissue closure. Ann Plast Surg. 2013; 70(1):74–78
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