Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

517
Aladdin H. Hassanein, MD, MMSc,
and William G. Austen, Jr., MD

What is the dif erence between “headache” and a “migraine headache”?
• A migraine is a speci c type o headache which meets diagnostic criteria that is sub-categorized by the presence
or absence o an aura (reversible neurological symptoms preceding the onset o migraine).
• Migraine without aura is de ned as ≥5 attacks that (1) last 4 to 72 hours; (2) include ≥2 speci c qualities
(pulsating, unilateral location, moderate–severe intensity, aggravation by routine activities); and (3) associated
with nausea/vomiting or photophobia.
• Migraine with aura is characterized by ≥2 episodes o headaches ul lling “migraine without aura” criteria
accompanied by aura ≤60 minutes in duration.

How common are migraine headaches?
• A ects 12% o the population
• T ree times more common in women

What is the pathophysiologic mechanism o migraine headaches?
T e exact etiology is unknown. T e mechanism may involve activation o nociceptive sensory bers o the
trigeminal nerve which innervate meningeal vessels (trigeminovascular system). Altered cortical excitability
and cortical spreading depression may a ect the pathway. Peripheral nerve irritation/sensitization and myelin
abnormalities recently have been implicated.

What pharmacological therapies are available or migraines?
• Acute analgesic—acetaminophen, nonsteroidal anti-inf ammatory drugs, narcotics
• Acute abortive—triptans, ergotamine
• Prophylactic—beta-blockers, anticonvulsants, tricyclic antidepressants
Surgical Management of
Migraine Headaches
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What nonpharmacological treatments are available or migraines?
• Behavioral (e.g., avoidance o environmental triggers)
• Botulinum toxin (Botox)
• Surgical treatment

How was a surgical option or migraine management discovered?
Guyuron et al. observed improvement o headaches in patients that underwent aesthetic rejuvenation o the brow.

Which patients may be considered candidates or surgical treatment o migraine?
Patients with chronic, debilitating re ractory migraine headaches that persist despite treatment by a neurologist
with maximal medical therapy. Imaging is obtained to rule out intracranial or rhinogenic etiologies. History and
physical examination should be consistent with a nerve trigger point. Response to Botox and/or nerve block can be
correlative.

What is the surgical goal o migraine treatment?
Decompression/deactivation o peripheral nerve triggers that have been identi ed preoperatively as a likely
migraine potentiator (synonymous to compressive neuropathies like carpal tunnel syndrome).

What basic anatomical structures may compress/irritate involved peripheral nerves and trigger migraine?
• Bone—compression through oramen/notch that nerve may exit (e.g., supraorbital oramen)
• Fascia—entrapment rom ascial element (e.g., trapezius ascia)
• Muscle—compression rom entry or exit into a muscle (e.g., corrugator muscle)
• Vascular—vessel crossing nerve (e.g., occipital artery)

What are the migraine trigger points and which nerves are involved?

What are nasoseptal triggers o migraine?
• Aberrant intranasal mucosal contact points may trigger migraines by irritation o trigeminal nerve branches:
anterior ethmoidal nerve (V1) and sphenopalatine ganglion (V2 contributions).
• Etiology includes deviated septum, spurs, turbinate hypertrophy, paradoxical turbinate curvature, concha
bullosa (pneumatized turbinate), Haller cells (in raorbital ethmoid cells).

How are nasoseptal causes o migraine surgically treated?
Septoplasty and turbinate resection to relieve abnormal septal contact points.
Trigger Site
Nerves
Frontal
Supratrochlear (V1), supraorbital (V1)
Temporal

Zygomaticotemporal (V2), auriculotemporal (V3)
Occipital

Greater Occipital (C2), lesser Occipital (C2)

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What are the three divisions o the trigeminal nerve (cranial nerve V) and the oramen that they exit?
• Ophthalmic division (V1)—superior orbital ssure
• Maxillary division (V2)— oramen rotundum
• Mandibular division (V3)— oramen ovale

What are the three branches o V1?
• Frontal nerve
• Lacrimal nerve
• Nasociliary nerve

What three nerves does the rontal branch o V1 divide into?
• Supraorbital nerve
• Supratrochlear nerve
• In ratrochlear nerve

Which nerves may be involved in rontal migraine headaches?
• Supraorbital nerve
• Supratrochlear nerve

Which muscles may compress the supratrochlear and supraorbital nerve?
Corrugator supercilii and depressor supercilii, which are resected during rontal migraine decompression.

Does the supraorbital nerve more commonly exit through a notch or oramen?
Supraorbital notch is more common (83%). Either a oramen or notch (with ascial band) may cause compression.

How is rontal migraine decompression surgically approached?
Either (1) endoscopically or (2) a transpalpebral (upper blepharoplasty) incision.

Which nerves may be involved in temporal migraine headaches?
• Zygomaticotemporal nerve
• Auriculotemporal nerve

T e zygomaticotemporal and auriculotemporal nerves are branches o which nerves?
• Zygomaticotemporal nerve: branch o the maxillary division o the trigeminal nerve (V2)
• Auriculotemporal nerve: branch o the mandibular division o the trigeminal nerve (V3)

Which muscle does the zygomaticotemporal nerve course through?
emporalis muscle (50%).

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Plastic & Reconstructive Surgery Board Review

Which vessel travels closely with the auriculotemporal nerve?
Super cial temporal artery and vein.

Which nerves are implicated in occipital migraine headaches?
• Greater occipital nerve (most common)
• Lesser occipital nerve
• T ird occipital nerve—no longer considered a signi cant migraine trigger

Are the nerves involved with occipital migraines branches rom the trigeminal nerve? Which nerves do they
arise rom?
• No, nerve triggers o occipital migraine triggers are rom cervical spinal nerves not the trigeminal nerve.
• Greater and lesser occipital nerves are rom the second cervical spinal nerve (C2) and the third occipital nerve is
rom C3.

Which structures can compress the greater occipital nerve
• Capitis muscles (semispinalis, obliquus)
• rapezius/trapezius ascia
• Occipital artery

What is the success rate o surgical treatment o migraine in appropriately selected patients?
• Up to 90% success rate (de ned by reduction in symptoms by at least 50%).
• 50% experience total elimination o headaches.

Is there any Level I evidence supporting a surgical migraine therapy?
Yes, Guyuron et al. per ormed a placebo-controlled trial using a sham surgical group which demonstrated that
operative treatment o migraines was e ective.
REFERENCES
Behin F, Behin B, Bigal ME, Lipton RB. Surgical treatment o patients with re ractory migraine headaches and intranasal contact points.
Cephalalgia. 2005;25:439–443.
Bernstein C, Burstein R. Sensitization o the trigeminovascular pathway: perspective and implications to migraine pathophysiology.
J Clin Neurol. 2012;8:89–99.
Fallucco M, Janis JE, Hagan RR. T e anatomical morphology o the supraorbital notch: clinical relevance to the surgical treatment o
migraine headaches. Plast Reconstr Surg. 2012;130:1227–1233.
G rerer L, Maman DY, essler O, Austen WG Jr. Nonendoscopic deactivation o nerve triggers in migraine headache patients: surgical
technique and outcomes. Plast Reconstr Surg. 2014;134:771–778.
Guyuron B. Rhinogenic migraine headaches. In: Guyuron B, ed. Rhinoplasty. 1st ed. China: Saunders; 2012:441–448.
Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment o migraine headaches. Plast Reconstr Surg. 2005;115:1–9.
Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S. A placebo-controlled surgical trial o the treatment o migraine
headaches. Plast Reconstr Surg. 2009;124:461–468.
Guyuron B, Varghai A, Michelow BJ, T omas , Davis J. Corrugator supercilii muscle resection and migraine headaches. Plast Reconstr
Surg. 2000;106:429–234.

CHAPTER 53 Surgical Management o Migraine Headaches
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Guyuron B, Yohannes E, Miller R, Chim H, Reed D, Chance MR. Electron microscopic and proteomic comparison o terminal
branches o the trigeminal nerve in patients with and without migraine headaches. Plast Reconstr Surg. 2014;134:796e–805e.
International Headache Society (IHS). IHS International Headache Classif cation II. Available at: ihs-classi cation.org/en. Accessed
March 30, 2015.
Janis JE, Barker JC, Javadi C, Ducic I, Hagan R, Guyuron B. A review o current evidence in the surgical treatment o migraine
headaches. Plast Reconstr Surg. 2014;134:131S–41S.
Janis JE, Hate DA, Ducic I, et al. T e anatomy o the greater occipital nerve: Part II. Compression point topography. Plast Reconstr
Surg. 2010;126:1563–1572.
Janis JE, Hate DA, Hagan R, et al. Anatomy o the supratrochlear nerve: implications or the surgical treatment o migraine headaches.
Plast Reconstr Surg. 2013;131:743–750.
Janis JE, Hate DA, T akar H, et al. T e zygomaticotemporal branch o the trigeminal nerve: Part II. Anatomical variations. Plast
Reconstr Surg. 2010;126:435–442.
Lee M, Lineberry K, Reed D, Guyuron B. T e role o the third occipital nerve in surgical treatment o occipital migraine headaches.
J Plast Reconstr Aesthet Surg. 2013;66:1335–1339.
Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF; AMPP Advisory Group. Migraine prevalence, disease burden,
and the need or preventive therapy. Neurology. 2007;68:343–349.
Olesen J, Burstein R, Ashina M, elt-Hansen P. Origin o pain in migraine: evidence or peripheral sensitisation. Lancet Neurol. 2009;
8:679–690.
Pietrobon D, Striessnig J. Neurobiology o migraine. Nat Rev Neurosci. 2003;4:386–398.

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523
Anish Gupta, MD, DDS and
Ruba Khader, BDS

What are the di erent types o teeth that are present in the adult dentition?
1. Incisors—anterior teeth, single rooted, used or biting/incising
2. Canines—anterior teeth, cornerstones o the mouth, prominent cusp tips, single long roots
3. Premolars—aka bicuspids, posterior teeth, occlusal sur ace to chew, commonly single rooted in mandible and
dual rooted in maxilla
4. Molars—posterior teeth used primarily or chewing, maxillary molars with three roots and mandibular molars
with two roots
See Figure 54-1.
Dental Anatomy and
Occlusion
CHAPTER 54
Figure 54-1 ypes o teeth.

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Plastic & Reconstructive Surgery Board Review

You are called in to consult on a 27-year-old male who has sustained acial trauma. He has multiple intraoral
and perioral lacerations and the crowns o his two maxillary central incisors are no longer present in his
mouth. When calling the dental trauma consultant, which teeth will you tell her are ractured?
eeth 8 and 9.
T e Universal Numbering System has been adopted by the American Dental Association. NUMBERS designate the
32 permanent (adult) teeth (1–32). Begin at the RIGH maxillary third molar (#1) to the LEF maxillary third
molar (#16), down to the LEF mandibular third molar (#17), and end at the RIGH mandibular third molar
(#32). Many individuals will have impacted third molars or have had their third molars extracted. T ere ore, you
will requently begin counting at tooth #2.
LE ERS designate the 20 primary (deciduous) teeth (A– ). See Figure 54-2.
Other systems in use include the International Numbering System and the Palmer Notation Method.
Permanent
maxillary
right first molar
Permanent
mandibular
right third molar
Permanent maxillary
left second premolar
Permanent
mandibular
left canine
Primary teeth
Primary
maxillary
right first molar
Primary maxillary
left second molar
Primary mandibular
left canine
Primary
mandibular
right lateral incisor
1
10
1112
2
13
3
4
5
6
7
8 9
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A
B
C
D E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
Permanent teeth
Figure 54-2 Universal numbering. Reproduced with permission rom intinalli JE, Kelen GD, Stapczynski JS, et al. Tintinalli’s Emergency
Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004. Fig. 242–2.

CHAPTER 54 Dental Anatomy and Occlusion
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What are the parts o the tooth and its housing?
1. Enamel—hard outer highly mineralized covering o the tooth crown composed mainly o hydroxyapatite.
2. Dentin—less mineralized structure than enamel that also includes organic material and water containing
microtubules. When exposed, teeth become sensitive.
3. Cementum—Located only on the root, it covers the dentin. It is less calci ed than enamel or dentin and
attaches to the periodontal ligament.
4. Pulp—neurovascular component o teeth also containing connective tissue and cells (odontoblasts). Pulpal
in ammation or exposure causes signi cant pain.
5. Periodontal ligament—connective tissue that attaches cementum to bone, allowing or movement o the tooth
in the socket as well as proprioception.
6. Alveolar bone—made o cortical and cancellous bone.
See Figure 54-3.
Crown
Root
Enamel
Dentin
Pulp
Cementum
Nerve and
blood
supply
Figure 54-3 Anatomy o the tooth and surrounding structures. Reproduced rom Stone CK, Humphries RL. Current Diagnosis & Treatment:
Emergency Medicine, 2008. 6th ed. New York, NY: McGraw-Hill. Fig. 30–11.

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Plastic & Reconstructive Surgery Board Review

Describe the ollowing anatomic terms used in describing sur aces o teeth:
1. FACIAL: part o tooth that aces the lips or cheeks. Can be urther subdivided into:
a. LABIAL: acial sur ace o AN ERIOR teeth (incisors and canines).
b. BUCCAL: acial sur ace o POS ERIOR teeth (premolars and molars).
2. PALA AL: sur ace o maxillary teeth that ace the palate.
3. LINGUAL: describes both maxillary and mandibular sur aces that ace the tongue.
4. MESIAL: OWARD the dental midline.
5. DIS AL: AWAY rom the dental midline.
6. OCCLUSAL: the chewing sur ace o the POS ERIOR teeth.
7. INCISAL: the biting sur ace o the AN ERIOR teeth.
See Figure 54-4.
Figure 54-4 Sur aces o teeth.

CHAPTER 54 Dental Anatomy and Occlusion
527

Describe the ollowing dental terminology.
CORONAL: re ers to the crown o the tooth, which is the portion o the tooth which is visible in the mouth.
“Coronal” can be used as a directional term. For example, the incisal edge o an incisor is coronal to the gingiva.
APICAL: the apex o the tooth is at the root end. T e root is the portion o the tooth which is housed in the
alveolar bone. T e term “apical” can also be used as a directional term. For example, starting at the incisal edge
and moving apically, one would reach the root o the tooth.
CINGULUM: the cingulum is a bulge on the lingual sur ace o anterior teeth.
HEIGH OF CON OUR: all teeth have heights o contour (crests o curvature) which re er to the location o
greatest contour o the crown o the tooth.
See Figure 54-5.
Figure 54-5 ooth #24 pro le view.

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Plastic & Reconstructive Surgery Board Review

Describe the ollowing occlusal relationships.
1. Overbite: VER ICAL overlap between the maxillary and mandibular central incisal edges. See Figure 54-6A.
2. Overjet: HORIZON AL distance between the maxillary and mandibular central incisal edges. See Figure
54-6B.
3. Crossbite: a NEGA IVE overJE relationship (mandibular teeth FACIAL to maxillary teeth). See Figure
54-6C.
4. Openbite: a NEGA IVE overBI E relationship—a VER ICAL opening between maxillary and mandibular
teeth incisal edges/occlusal sur aces. See Figure 54-6D.
A
C

D
B
Overbite
Overjet
Figure 54-6A: Overbite ( rontal view). B: Overjet in a severe angle class II patient (sagittal view). C: Dental crossbite. D: Anterior openbite. See
Color insert.

CHAPTER 54 Dental Anatomy and Occlusion
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As part o your acial cosmetic treatment plan on a 42-year-old emale patient, you have re erred her to an
orthodontist to correct her malposed teeth. T e patient has a normal skeletal structure and an appropriate
size and space or her ull dentition. T e orthodontist will place the patient in a normal overbite and overjet.
What angle classi cation would you expect her nal occlusal outcome to be?
Class I. Angle classi cation provides a way to describe the patient’s inter-arch occlusal relationship by de ning
inter-arch rst molar relationship. A maxillary rst molar has our cusp tips. T e mesiobuccal cusp is the most
anterior (mesial) and lateral (buccal) cusp. T e mandibular molar has a buccal groove visible which appears
to halve the lateral sur ace o the tooth. In class I molar occlusion, the mesiobuccal cusp tip o the maxillary
rst molar will lie on the buccal groove o the mandibular rst molar when the patient is biting down and is
completely in occlusion (maximum intercuspation). See Figure 54-7A.
In class II molar occlusion, the mesiobuccal cusp tip o the maxillary rst molar will be anterior to the buccal
groove o the mandibular rst molar. In many cases, this can be interpreted as anteriorly placed maxillary teeth in
relation to the mandibular teeth potentially leading to an increased overjet. O ten, a class II occlusion is the result
o maxillary hyperplasia or mandibular hypoplasia. See Figure 54-7B.
In class III molar occlusion, the mesiobuccal cusp tip o the maxillary tooth will be posterior to the buccal groove
o the mandibular tooth. In many cases, this can be interpreted as posteriorly placed maxillary teeth in relation to
the mandibular teeth potentially leading to a negative overjet (anterior crossbite). O ten, a class III occlusion is the
result o maxillary hypoplasia or mandibular hyperplasia. See Figure 54-7C.
More generally, a malocclusion is de ned as any misalignment o the teeth or imper ect relationship between
the two dental arches. Class II and class III angle classi cations are speci c types o malocclusion. Crowding and
spacing within a single dental arch can also cause more localized malocclusions.
Figure 54-7 A: Angle class I molar relationship. B: Angle class II molar relationship—note the anterior overjet and maxillary canine anterior
to the mandibular canine. C: Angle class III molar relationship—note the negative anterior overjet. See Color insert.
C
A

B

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Plastic & Reconstructive Surgery Board Review

Describe the di erence between class II division 1 and class II division 2 malocclusion.
Both have class II relationships. Division 1 patients have minimal crowding o maxillary teeth with a resultant
large overjet o the incisors, while class II division 2 patients demonstrate incisors that crowd in such a way so as
to diminish the overjet. T e central incisors are lingually inclined (“shoveled”) and the lateral incisors are acially
malpositioned (“ ared”).

Describe how the cingulum and height o contour contribute to the success ul placement o Erich archbars.
ighten the wire while apical to the height o contour.
T ink o the height o contour as the “waist” o the tooth. In anterior teeth, whose crowns appear triangular in
shape when viewed in pro le, the height o contour is at the neck o the tooth at the cingulum. It is critical to
have the interdental wire apical to this cingulum.

You are assessing a 32-year-old emale patient who sustained a acial trauma. T e patient had a helmeted
motorcycle collision and ell o her vehicle a ter striking road debris at low speed. She didn’t sustain any
critical injuries, but was ound to have an anterior openbite.

What signs in her occlusion would help you distinguish a preexisting openbite?
Mamelons.
Mamelons are ridges on the incisal edges o teeth that are generally worn o o adult teeth due to occlusion and
contact; however, they are o ten present in patients with open bites or severe class III malocclusions due to the lack
o occlusal contact. I the patient above (adult) had mamelons, then it is sa e to assume that she had a preexisting
open bite. See Figure 54-8.
Figure 54-8 Mamelons in an anterior open bite. See Color insert.
In a trauma patient, the sur aces o the teeth will act as a guide to the pretraumatic occlusion. Other wear patterns
or wear acets may also be help ul in identi ying where the pretraumatic occlusion needs to be set. A patient’s
occlusion many times will resemble a jigsaw puzzle which needs to be snugly t back together.
Causes o open bite:
1. ongue thrust.
2. Foreign object placed chronically between teeth (i.e., thumb, pencil).
3. rauma—o ten causing premature contacts on the posterior teeth.
4. Orthodontics—prior to orthognathic surgery.

CHAPTER 54 Dental Anatomy and Occlusion
531

When assessing a patient’s occlusion, you ask her to bite into maximum intercuspation. While gently
holding this bite, you then ask her to slide her mandible to the right. On observation o this slide, you see
that her posterior teeth are no longer in occlusion and that her canines are the only teeth touching. What do
you call this phenomenon?
Canine guidance.
Canine guidance is a characteristic o an ideal unctional occlusion. In lateral excursions o the mandible, a patient
with canine guidance will no longer occlude on the molars and premolars (immediate disclusion). In this lateral
slide, the lower canine ramps against the upper canine and provides the opening o the bite.
Group unction occurs when the premolars and molars continue to touch while the patient is per orming the same
lateral excursions. T is has the potential to be traumatic and can cause wear on the posterior teeth.
Anterior guidance is an occlusal phenomenon which occurs when a patient protrudes his jaw while maintaining
occlusal (or incisal) pressure. T e anterior teeth (incisors and canines) ramp o each other and create posterior
teeth disclusion.

You are a local surgeon in a rural setting. A ght broke out at the local high school dance, and one o your
patients in the ED received a punch to the ace. eeth 7, 8, 9, and 10 were avulsed and swallowed. You
currently note that the buccal gingiva was also degloved on the buccal alveolus. When reapproximating the
tissue, what structures will you suture together?
T e gingival papillae.
When adjacent teeth are in contact, healthy gingiva orms a scalloped margin between teeth. T e collar o gingiva
directly apical to the crown o the tooth is called the marginal gingiva.
T e triangular gingival tissue between the crows o adjacent teeth is known at the gingival papilla or interdental
papilla. Without the height o these papillae, unaesthetic “black triangles” orm between the teeth. Care to
reapproximate papilla in traumatic settings can prevent the ormation o these empty spaces between the teeth.
See Figure 54-9.
Figure 54-9 Gingival architecture.

While doing an oral assessment on an intubated and sedated patient in the ICU you notice small quantities
o blood in the oral cavity. T e patient’s RN states that there is bleeding a ter providing oral cares. You are
unable to nd any traumatic sources o bleeding, but you do note that multiple teeth are mobile and there is
generalized erythema o the marginal gingiva. What is the likely source o the mobility and inf ammation?
Periodontal disease (gingivitis and periodontitis).
T e two most common diseases involved with loss o teeth are caries and periodontal disease. With poor oral
hygiene, bacterial load increases in the gingival sulcus around the teeth. T is in turn starts an in ammatory
process which ultimately leads to alveolar bone loss around the teeth and increases the depth o the gingival sulcus.
Common ndings include edematous rolled gingival borders, erythema, bleeding, and bone loss which shows the
root sur aces o the teeth.

532
Plastic & Reconstructive Surgery Board Review

A 12-year-old emale patient with history o cle t palate was lost to ollow up with your cranio acial practice.
She also has not maintained ollow ups with the remainder o the cle t lip and palate team. She returns or
assessment with complaints o an oronasal stula. She also has multiple malposed teeth with darkening and
shadowing o the enamel sur ace at the points o crowding. What are these lesions?
Carious lesions o the teeth.
Caries is a disease process attributed mainly to Streptococcus mutans, a normal oral inhabitant. Poor oral hygiene
provides an opportunity or bio lm ormation on the dentition. High-carbohydrate diet provides nutrients or
the bacteria in the bio lm, and acid is created as a metabolic byproduct. T is acid is what causes the erosion and
destruction o the teeth. Carious lesions tend to start in locations where this bio lm is dif cult to access, including
at the contacts o teeth and otherwise crowded areas.
REFERENCES
Nelson SJ. Wheeler’s Dental Anatomy, Physiology, and Occlusion. 10th ed. St. Louis, MO: Saunders; 2015.
Okeson JP. Fundamentals of Occlusion and Temporomandibular Disorders. 7th ed. St. Louis, MO: Mosby; 2012.

533
Peter W. Henderson, MD, MBA and
Evan Matros, MD, MMSc
GENERAL RECONSTRUCTION PRINCIPLES

What is the reconstructive ladder? What is the reconstructive elevator?
T e reconstructive ladder is the paradigm that dictates the traditional progression rom least to most complex
intervention or a given clinical scenario. T e usual sequence moves rom delayed wound healing to primary
closure, to skin gra t, to adjacent tissue trans er, to regional ap, and nally to ree ap.
T e “reconstructive elevator” is the concept that there are clinical scenarios which may bene t rom per orming
a more complex procedure, “skipping” lower rungs on the ladder. Increasingly sophisticated microsurgical
techniques can potentially allow or enhanced unction with less donor site morbidity. For example, a superior
outcome may be achieved with a ree anterolateral thigh ap rather than combining a hemi-gastrocnemius and
hemi-soleus or a large proximal and mid-tibial de ect.

What are the three basic modes o tissue movement o local aps?
Advancement, transposition, and rotation.
A rotation ap is a semicircular ap o skin and subcutaneous tissue that rotates about a pivot point into an
immediately adjacent de ect. A transposition ap is designed as a rectangle or square and crosses over areas o
skin/subcutaneous tissue. In contrast, advancement aps move directly orward without any rotation or lateral
movement.

What is di erence between random pattern, axial pattern, and per orator pedicle aps?
A random pattern ap has no single dominant vascular supply, instead just random blood supply running through
the various vascular plexuses (subepidermal, dermal, subdermal, subcutaneous, supra ascial, sub ascial). Because o
the limited blood supply, the length:width ratio is limited to 1–2:1.
An axial pattern ap contains a known vascular supply that is intentionally oriented longitudinally within a ap,
thereby increasing the potential length:width ratio.
A per orator ap is based on one or more o the vessels that per orate either muscle or connective tissue in order to
supply the skin and subcutaneous tissue used or the reconstruction. T e axial vessel does not need to be sacri ced.
Local and Regional
Flaps for Head and Neck
Reconstruction
CHAPTER 55

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Plastic & Reconstructive Surgery Board Review

What are Langer’s lines? What are the relaxed skin tension lines? Are there any points at which they are in
con ict?
Langer’s lines are de ned by the direction that skin splits when pierced with a spike. It corresponds to the direction
o collagen bers in the dermis.
Relaxed skin tension lines (RS L) run perpendicular to the direction o muscle contraction. It is thought that
orienting incisions along RS L results in improved cosmetic outcomes.
In most areas o the ace, the Langer’s lines and RS L are in harmony; however, they are in con ict at the nasal
supratip, the lateral canthi, and the glabella.

Which anatomic landmarks o the head and neck do not tolerate asymmetry or distortion?
Hairline, eyebrows, eyelids, medial and lateral canthi, nasal tip, nasal alae, earlobes, philtrum, vermillion, and oral
commissures.
T ese landmarks do not tolerate distortion or a variety o reasons. In some instances, structures are paired,
highlighting di erences between the right and le t side. In other cases, there are xed proportions between two
structures which cannot either exceed or be less than normal anthropometric proportions. For example, the
nasolabial angle o the nasal tip rotation must be within a small range be ore abnormalities become obvious.

What is a Burow triangle?
Advancing a skin ap can result in excess bunching on either side o the ap’s base. T is excess, which lies in the
skin immediately adjacent to the ap’s base, results rom a length discrepancy between the moving ap edge and
the stationary adjacent skin. It can be excised as a triangle called a Burow triangle. A Burow triangle may also be
excised along the outer edge o a rotational ap. Burow triangles o ten do not need to be excised in the scalp since
they are o ten covered by hair and requently become less prominent over time.

What is a bilobed ap? Describe the key points o its design.
T e bilobed ap is a double transposition ap that lls a circular de ect with a primary ap, and then transposes a
secondary ap into the primary ap de ect to recruit lax tissue rom arther away than a single transposition ap
would allow. T e tension is distributed across both transpositions.
1. T e primary ap should be the same size as the de ect, and slightly longer because the ap will shorten as it is
transposed.
2. Position the secondary ap in an area o laxity. For the nose, this is usually a vertically oriented pennant placed
at the sidewall or dorsum. A horizontal secondary ap closure will elevate the nasal tip.
3. T e secondary ap should be hal the width o the primary ap.
See Figure 55-1.
S
P
P
S
Figure 55-1 Bilobed ap.

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What is the maximum angle o transposition when using a bilobed ap?
According to the Zitelli modi cation, the maximum angle o transposition is 90 to 100 degrees (45–50 degrees
per lobe). T e original bilobed ap described by Esser was rotated a total o 180 degrees, but resulted in excessive
tension on the skin closure.

What is a rhomboid ap? Describe the key points in its design.
T e rhomboid ap is a transposition ap that lls a rhomboidal de ect with a matching adjacent rhomboidal ap.
Circular de ects can be made rhomboidal by excising a small amount o additional tissue.
1. T e de ect must be a rhomboid with 60- and 120-degree angles.
2. T e sides o the de ect should be equal in length and parallel. Flap dimensions should be the same size and
shape as the de ect.
3. Although our possible rhomboid aps are available or any de ect, the ap should be chosen based on location
o laxity, scar direction, and vascularity.
See Figure 55-2.
Figure 55-2 Rhomboid ap.
A
B
B′
A′

How can a large circular de ect be closed with rhomboid aps?
Conversion to a hexagon allows closure with three rhomboid aps rom the perimeter.

How does the Du ourmentel ap di er rom the Limberg rhomboid ap?
T e Du ourmentel ap uses a smaller degree o transposition and can thus be used or de ects with angles up to
90 degrees. In Figure 55-3, C-F is oriented to bisect A-C-D, and E-F is parallel to D-B.
A
B
C
D
F
E
Figure 55-3 Du ourmentel ap.

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Describe the design o the V-Y advancement ap.
T e V-Y advancement ap is designed with the open side o the “V” adjacent to the de ect. Flap length is
approximately 1.5 to 2 times the de ect length. A ter the ap is advanced into the de ect, the resultant donor area
is closed as a line which appears as a “Y.”

In addition to f lling de ects, how else can a V-Y advancement ap be used?
A V-Y advancement ap can be used to lengthen structures such as the columella, and release tension in areas
without a de ect. T e “V” incision is placed with the open side acing the direction o lengthening or excess
tension. See Figure 55-4.
A
B
Figure 55-4 V-Y advancement ap.

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What is the total area that should be CP -coded or a local rotational ap measuring 25 cm2 to cover a
cheek de ect measuring 4 cm in diameter?
For adjacent tissue trans ers, the area to be coded is the sum o the primary de ect and ap area. T e primary
de ect in this case measures 13 cm2 (A = πr2), and the ap area measures 25 cm2, or a total o 38 cm2.
NASAL RECONSTRUCTION

What is the blood supply to the external nose?
1. External carotid artery → acial artery → angular artery → lateral nasal artery
2. External carotid artery → acial artery → superior labial artery → columellar branch
3. External carotid artery → internal maxillary artery → in raorbital artery
4. Internal carotid artery → ophthalmic artery → anterior ethmoidal artery → external nasal branch
5. Internal carotid artery → ophthalmic artery → dorsal nasal artery (anastomoses with the lateral nasal artery)

What is the innervation to the external nose? o the internal nose?
External: In ratrochlear nerve (radix), in raorbital nerve (sidewalls), anterior ethmoid nerve—external branch
(tip, alae)
Internal: Anterior ethmoid nerve—internal branch (septum, internal nasal walls), nasopalatine nerve (septum),
lesser palatine nerve (nasal cavity)

Describe the A-to- or O-to- ap.
T e A-to- or O-to- ap is a double advancement ap that can be used to close triangular or circular de ects. T e
arms o the resultant “ ” lie at the base o the triangular de ect or tangent to the circular de ect. See Figure 55-5.
Defect
Incision
Figure 55-5 “A-to- ” or “O-to- ” ap.

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What are the two general contour classes into which the nasal subunits all? And what is the ideal
reconstructive element or each class?
Convex (e.g., nasal tip and alae) and at (e.g., sidewalls). Convexities are best replaced by aps, which contract
spherically, whereas at areas can be replaced by ull-thickness skin gra ts, which contract in a linear manner.

What are the three conceptual layers that must be considered when ormulating a plan or nasal
reconstruction?
Lining (mucosa), support (cartilage), and coverage (skin).

What are the di erences in skin quality between the di erent nasal subunits?
T e skin o the dorsum and sidewalls tends to be thin and smooth, while the skin o the tip and alae is dense and
sebaceous.

How many aesthetic subunits compromise the external nose? How much o any given subunit must be lost
in order to recommend removal o the entire subunit during reconstruction?
Nine subunits (paired sidewall, paired alae, paired so t triangles, dorsum, tip, columella). O note, some will
include the nasal root as the tenth subunit.
I > 50% o any given subunit is missing, some recommend removal o the entire subunit leads to be a better
aesthetic result. See Figure 55-6.
Root
Dorsum
Lateral sidewall
Alae
Soft tissue triangle
Columella
Tip
Figure 55-6 Aesthetic subunits o the nose.

Is healing by secondary intention an appropriate option or management o nasal de ects?
Healing by secondary intention may be acceptable or smaller de ects o the upper two-thirds o the nose, as well
as neighboring areas, including the glabella and medial canthal region. It is generally unacceptable or de ects o
the lower nose, including the tip, ala, rim, and so t triangle, where contracture results in signi cant distortion and
resultant skin quality is unsatis actory.

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What are potential donor sites or ull-thickness skin gra ting o nasal de ects?
Preauricular, postauricular, and supraclavicular skin provide the best color and quality match or nasal skin.

When may a superf cial nasal de ect be closed by a local ap?
De ects o less than 1.5 cm can generally be lled with local aps rom the relatively mobile and pliable skin o the
nasal sidewall.

What are the indications or using a single-lobed ap such as a banner ap on the nose?
Single-lobed aps may be used in de ects less than 1.5 cm in the upper two-thirds o the nose where the thin and
pliable skin provides better aesthetic results than a skin gra t. In the lower thirds o the nose, transposition o a
single-lobed ap through a large arc can distort the ala or tip.

What are the indications or using a bilobed ap in nasal reconstruction?
Lower third nasal de ects < 1.5 cm in size. ypically a laterally based ap is used or nasal tip de ects, whereas a
medial-based ap is used or the ala.

What layer should undermining or a bilobed ap in the nose be per ormed?
Submuscular (super cial to the perichondrium and periosteum).

Describe the nasolabial ap.
T e nasolabial ap is designed with its medial edge in the nasolabial crease to hide the resultant scar in the crease.
It can be superiorly or in eriorly based and can be per ormed in one stage (island ap) or two stages (pedicled ap
requiring delayed division).

What is the blood supply o the nasolabial ap?
Per orators rom the acial artery and angular artery supply the in eriorly and superiorly based nasolabial aps,
respectively. It is considered to be a random ap.

What are some indications or the superiorly and in eriorly based nasolabial aps?
Superiorly based aps are well suited or large de ects (1.5–2.5 cm) o the nasal ala, dorsum, and sidewall.
In eriorly based aps are more suited or the reconstruction o the upper lip and oral cavity.

What are some problems with using the nasolabial ap or nasal alar reconstruction?
Potential mismatch between cheek and nasal skin color and texture. Loss o the concave border between the cheek
and ala.

When can the cheek be used or nasal reconstruction?
Cheek advancement aps can be used or nasal sidewall de ects (~1.5 cm). However, doing so can lead to a loss o
distinction between the cheek and nose (a “bowstring” appearance). T ese aps should be divided at a later stage
intentionally creating a scar at the junction between the aesthetic units.

What is the dominant vascular supply to the rontonasal advancement ap?
Otherwise known as a Rieger, dorsal nasal, or miter ap, the rontonasal advancement ap is supplied by the
angular artery.

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What are the indications or use o the rontonasal ap?
ransverse de ects close to the midline in either the lower or middle third o the nose.

What is a glabellar ap? What is the location o a de ect best treated by a glabellar ap?
T e glabellar ap is essentially a vertically oriented banner (unilobe) ap harvested rom the midline o the
glabella. Glabellar aps are good solutions or reconstructing de ects o the medial canthi.

T e paramedian orehead ap is based on what vessel?
T e supratrochlear artery, with contributions rom the rich anastomotic arcade comprised o the in ratrochlear,
dorsal nasal, and angular arteries.

In which layers does the vascular pedicle to the paramedian orehead ap travel?
T e supraorbital and supratrochlear arteries travel just super cial to the periosteum initially, then emerge just deep
to the dermis near the hairline. T ere ore, the distal tip o the ap can be raised with just skin and a small amount
o subcutaneous tissue, whereas near the orbital rims the dissection has to be carried deep to the rontalis, just
above the periosteum.

What are three ways to increase the length o a paramedian orehead ap?
1. Extend the ap into hair-bearing scalp (requires secondary depilation procedure).
2. Extend the base o the ap up to 1.5 cm in erior to the superior orbital rim.
3. Score the rontalis muscle.

What is the approach or dealing with the situation where an adequately sized paramedian orehead ap will
leave too large a orehead de ect or primary donor-site closure?
Most paramedian orehead ap donor sites contract adequately with time and heal by secondary intention or can
be easily camou aged with a skin gra t. Do not compromise the reconstruction o the recipient site or the sake o
the donor site.

What are some options or nasal lining replacement?
1. Redundant skin olded over rom the coverage ap.
2. Skin gra t.
3. Mucoperichondrial ap rom the septum.
4. Rotational or advancement ap rom residual vestibular lining.
5. Facial artery musculomucosal (FAMM) ap.
6. Free ap rom the radial orearm or anterolateral thigh.

What are three common donor sites or reconstructing the cartilaginous ramework o the nose?
T e nasal septum, auricular conchal cartilage, and rib cartilage.

What is the ideal so t-tissue donor or the reconstruction o a small isolated alar margin de ect?
Composite auricular gra t.

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What reconstructive option or small composite de ects o the ala provides the best aesthetic results?
Composite gra ts including cartilage rom the ear. Ear gra ts provide excellent color, texture, and structural match.
In addition, it provides both extranasal skin and intranasal skin or lining.

T e alar wings do not normally contain cartilage; why must they be supported by cartilage when reconstructed?
o provide support or the thin so t-tissue contour that normally is not stressed, but a ter reconstruction is subject
to the centripetal contractile orces o healing.

How big a de ect can a composite auricular gra t reliably f ll? What limits this size?
Because an auricular composite gra t or alar rim reconstruction contacts the wound bed along an edge, rather
than a broad sur ace, neovascularization is signi cantly limited and in turn limits gra t size to approximately
1.5 cm. No portion o the gra t should be more than 5 to 8 mm away rom the nourishing wound bed.

What are some treatments that can potentially augment survival o auricular composite gra ts?
1. Cooling in the rst ew days a ter gra ting can reduce the metabolic rate o the gra t suf ciently while
neovascularization is initiated. However, a ter the rst week, this can be detrimental to gra t survival due to
vasoconstriction.
2. Hyperbaric oxygen.

Describe the progression in physical appearance o an auricular composite gra t rom hours to months
a ter gra ting.
1. 6 to 8 hours—pale
2. First day or two—pink tinged
3. First week—cyanotic due to venous congestion
4. Second– ourth weeks—pink, then red
5. 6 months—normalization o color

What is the best option or reconstructing the columella?
While more complex reconstructive options, such as ascending helical auricular ree aps, may be necessary or
more extensive de ects, auricular composite gra ts are a good rst choice in most situations.

What is the presumed etiology o rhinophyma? What is the best treatment?
T e exact etiology o rhinophyma is unknown, but it is thought to be related to rosacea resulting in a bulbous,
pustular nose. Historically, it was associated with alcohol consumption, but this relationship has been re uted.
T e optimal treatment is tangential excision and skin gra ting (though other modalities such as ablative laser and
mechanical dermabrasion have been reported).
LIP RECONSTRUCTION

What is the blood supply to the lip?
T e in erior and superior labial arteries rom the acial artery.

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What is the location o the acial artery relative to the masseter muscle?
Anterior and super cial.

What nerve is at risk or injury when exposing the acial artery adjacent to the masseter?
Marginal mandibular branch o acial nerve (cranial nerve VII).

Where does the in erior labial artery branch rom the acial artery?
2.5 cm lateral and 1.5 cm in erior to the oral commissure.

What does the acial artery continue as in the mid ace?
It ascends as the angular artery, which contributes lateral nasal branches to the ala that anastomose with the dorsal
nasal artery, a branch o the ophthalmic artery. T e acial and labial arteries communicate with the subdermal
plexus through a dense population o musculocutaneous per orators.

What is the sensory innervation to the lip?
In raorbital nerve (central portion o upper lip), mental nerve (central portion o lower lip), and buccal branch o
V3 (commissures).

Which two nerves may become non unctional ollowing hemi-mandible resection?
Marginal mandibular branch o acial nerve (cranial nerve VII): particularly vulnerable when elevating the cheek
to expose the mandible.
In erior alveolar nerve: sacri ced during the bony resection (the nerve runs within the body o the mandible).

What muscles o acial expression are innervated on their superf cial sur ace?
T e mentalis, levator anguli oris, and buccinator (“MLB”).

What are the goals o lip reconstruction?
1. Skin cover/oral lining.
2. Reestablishment o vermillion.
3. Adequate stomal diameter.
4. Sensation.
5. Oral competence (normal oral sphincter unction).

Do the upper and lower lips contribute equally to oral competence?
No, the upper lip does not contribute signi cantly to oral competence.

What are the limits o primary closure o the lower lip in terms o tissue loss? What about the upper lip?
Lower lip de ects up to 40% can be closed primarily whereas upper lips de ects o only 25% can be closed
primarily without signi cant anatomical distortion.

What is the di erence between direct primary closure o the upper lip as opposed to the lower lip?
T e unique anatomic landmarks o the upper lip (Cupid’s bow, philtral columns) make the upper lip less exible
than its lower counterpart or direct primary closure.

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What options are available or replacement o vermilion tissue?
1. Healing by secondary intention
2. Mucosal advancement aps
3. Vermilion lip switch
4. wo-stage tongue ap
5. Buccal mucosal advancement
6. FAMM ap

What layers are included in a FAMM ap?
Mucosa, submucosa, buccinator, the deep layer o orbicularis oris, and the acial artery.

How does the FAMM ap di er rom buccal mucosal advancement aps and musculomucosal V-Y
advancement aps in terms o blood supply?
T e FAMM ap provides tissue with an axial blood supply, whereas the latter aps have only random pattern
blood supplies.

What is the key concern in using intraoral mucosa or the reconstruction o dry vermilion?
Chronic dry lips.

What general strategies are used in lip reconstruction?
1. Rotation-advancement o the remaining uninvolved lip peripheral to the de ect
2. Lip-switch aps

What is lip-switching?
Using tissue rom one lip to reconstruct the other, based on the dual blood supply to the lips rom the acial artery.
T e two main procedures that employ a lip-switch technique are the Abbe and Estlander aps.

What is the blood supply to the Abbe ap?
ypically, the Abbe ap is per ormed on the lower lip to reconstruct the upper lip, in which case it is based on the
in erior labial artery. T e artery runs deep to the orbicularis muscle. On sagittal sectioning it lies at the level o the
white roll.

What are the indications or using an Abbe ap?
Closure o philtral or paramedian de ects not involving the commissure.

How large should an Abbe ap be?
T e ap should measure one-hal the width o the upper lip de ect. In reconstructing the philtrum, the ap should
be no larger than 10 mm wide and 15 mm long; some surgeons advocate an even smaller ap.

How does the Estlander ap di er rom the Abbe ap? What artery is it based on, and what is it used or?
Estlander’s derivation o the Abbe ap involves a triangular ap based on the contralateral labial artery. It provides
coverage or de ects involving the commissure. While the ap typically is taken rom the upper lip to reconstruct
lower lip de ects, it can also be reversed to cover upper lip de ects with lower lip tissue. T e Estlander ap is a
usually a single stage procedure, whereas the Abbe ap requires a second procedure or pedicle division.

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What is the Gillies an ap used or?
As a rotational advancement ap, the Gillies an ap donates upper lip and cheek tissue to close large central
lower lip de ects. Several modi cations o this original concept have been established. McGregor (1983) initially
described a rectangular musculocutaneous ap similar to Gillies, but with a more narrow base and thus without
the distortion o the modiolus. T e Gillies ap can also be used or the reconstruction o upper lip de ects. T e
name is derived rom the ap shape and direction o movement which resembles the opening o a an.

Describe the Karapandzic ap and its indications.
T e Karapandzic ap is an innervated orbicularis oris composite ap designed with a circumoral incision
camou aged in the nasolabial olds. It is used to repair midline and total upper and lower lip de ects.

What is unique about the Karapandzic ap compared to the Abbe and Estlander aps?
T e Karapandzic ap is innervated (the buccal branch o the acial nerve, and the buccal trigeminal sensory
branches).

When local or regional aps are not available, what is the next step in lip reconstruction? What are some
problems with those options?
T e ree tissue o choice in lower-lip reconstruction is the radial orearm ree ap with palmaris tendon or oral
competence. In general, however, this is ar rom ideal compared to local or regional aps due to ap bulk,
dif culty in restoring oral competence, and poor aesthetic match. Because the upper lip does not contribute
signi cantly to oral competence, there is even less reason to use ree tissue in upper lip reconstruction.

For each ap (Abbe, Modif ed Bernard-Burow, Estlander, Gillies, Karapandzic) describe the advantages and
disadvantages.
Abbe ap:
• Advantages—ideal or central de ects o the upper lip (philtral), color match, and rapid reinnervation
• Disadvantages—pedicled ap con guration requiring secondary division, minor secondary vermilion
discrepancies
Estlander ap:
• Advantages—optimal or reconstruction o lateral commissure de ects
• Disadvantages—microstomia, ablation o the natural shape o the commissure
Gillies an ap:
• Advantages—suitable or large lower lip de ects
• Disadvantages—may reduce the aperture o the mouth similar to the Estlander ap, disrupts and displaces the
modiolus, and distortion o the lip and lack o neural supply can lead to severe aesthetic de ormities and oral
incompetence
Karapandzic ap:
• Advantages—neurovascular rotational ap provides reconstruction with a competent oral sphincter
• Disadvantages—similar to the Gillies and Estlander aps, distortion and displacement o the modiolus occurs
Modi ed Bernard–Burow ap:
• Advantages—scars are camou aged within natural creases along alar base and sill, can be used or de ects up to
80% when the ap is raised bilaterally.
• Disadvantages—displacement o philtral columns, distortion o nasolabial old

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How much o the oral circum erence must be lost in order to develop microstomia? What trade-o s must be
considered when deciding between local or ree tissue trans er or the reconstruction o large lip de ects?
Resection o > 50% o the total lip circum erence o ten results in unctional microstomia.
Utilizing a ree ap (radial orearm, etc.) introduces additional tissue, thereby reducing the likelihood o
microstomia. T e trade-o is absent sensation and poor oral competence with chronic drooling.

What is the “whistling de ormity,” and what causes it? How can it be treated?
T e “whistling de ormity” is a de ciency in the vertical length o the lip that prevents complete closure. A
whistling sound may be heard during normal respiration.
I it does occur, the most important element o reconstruction is repairing the orbicularis oris muscle. In addition,
some sort o vermillion lengthening procedure can be per ormed (V-Y, z-plasty, etc.).
CHEEK RECONSTRUCTION

What is the sensory and motor innervation to the cheek?
Sensory: V2 and V3 branches o the trigeminal nerve (cranial nerve V).
Motor: Zygomatic, buccal, and marginal mandibular branches o the acial nerve (cranial nerve VII), and V3
branch o trigeminal nerve (cranial nerve V) which innervate the temporalis and masseter muscles.

What are the aesthetic zones o the cheek?
Suborbital, preauricular, and buccal mandibular.

Which method creates the earliest postoperative smile restoration ollowing acial nerve sacrif ce: temporalis
myoplasty, ascia lata sling, cross acial nerve gra t, or V3 nerve trans er? Which creates the second-earliest?
Earliest: emporalis myoplasty.
Second-earliest: V3 nerve (nerve to masseter) trans er.

What are the best options or reconstructing small, medium, and large cheek de ects?
1. Small: Local aps (rhomboid, nasolabial, V-Y, banner/unilobed, bilobed aps)
2. Medium: Cervico acial aps (Mustarde)
3. Large: Cervicopectoral aps

What are the indications or tissue expansion in cheek reconstruction?
Because large skin gra ts on the ace result in poor color match and overall appearance, they are generally
undesirable. A skin gra t can be placed as a biologic dressing, ollowed by tissue expander placement, and nally a
cervico acial ap closure. Alternatively, or benign processes, such as AVM or congenital nevus, the tissue expander
can be placed rst, with immediate reconstruction at the time o tumor excision.

Describe the submental ap.
T e submental ap is a musculocutaneous platysma ap based laterally on the submental artery. Blood supply is
the submental branch o the acial artery that runs parallel to the anterior belly o the digastric muscle. It provides
skin that is a good match or acial skin. In men, since this is typically hair-bearing skin, it can be advantageous or
the reconstruction o hair-bearing areas.

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What are the indications or using the submental ap?
1. Extraoral de ects o the lower ace, mid ace, and even in erior upper ace.
2. Intraoral de ects as ar posteriorly as the base o the tongue and as ar superiorly as the palate.
3. Combined intraoral and extraoral de ects, by skin gra ting the undersur ace o the platysma muscle.
4. Since the ap comes rom hair-bearing skin (in men), it can be used or the reconstruction o hair-bearing areas
such as the upper lip.

What is a contraindication to using the submental ap in head and neck tumor reconstruction?
Ipsilateral neck dissection (excision o the submandibular gland usually results in ligation o the terminal branch o
the acial artery).

Describe the Juri cervico acial ap.
Juri’s modi cation o the cervico acial ap is a rotational ap, based in eromedially on the acial and submental
arteries, used primarily to cover upper medial cheek de ects. T e incision extends laterally rom the de ect parallel
to the zygomatic arch, turns in eriorly along the preauricular old, then extends in erior to the ear be ore turning
posteriorly along the retroauricular hairline. T e ap is then rotated superomedially.

What is the major advantage and disadvantage o using in erolaterally based cervico acial aps?
In erolaterally based aps tend to exhibit less risk o necrosis. However, the incision is more anterior and medial
in the ace and neck. Where the incision crosses the mandibular border, a Z-plasty can serve to prevent later
development o contracture.

In what layer is the dissection o cervico acial aps carried out?
Subcutaneous (staying super cial to super cial musculoaponeurotic system [SMAS] will reduce likelihood o acial
nerve injury).

Can the dissection be carried out in a di erent layer, and what is the advantage in doing so?
Some authors advocate dissection o cervico acial aps in a sub-SMAS layer to improve the blood supply,
especially in smokers and patients with poor skin quality (though this increases the risk o injury to the acial
nerve).

What complication can result rom excessive tension at the malar eminence when using cervico acial and
cervicopectoral aps?
Lower lid ectropion can occur i downward tension is placed on the so t tissue o the malar eminence. o prevent
this, anchor sutures can be placed in the periosteum o the zygomatic arch. In some instances, a lateral canthopexy
can help as well.

How can the rontal branch o the acial nerve be avoided when anchoring sutures to the periosteum o the
zygomatic arch?
T e rontal branch does not cross the arch more than 3.5 cm anterior to the external auditory canal. By staying
anterior to this, injury to the rontal branch can be avoided.

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Describe the cervicopectoral ap.
T e cervicopectoral ap is a myocutaneous ap based medially on anterior thoracic per orators o the internal
mammary artery, used or de ects o the lower lateral cheek. T e incision extends rom the de ect posteriorly,
passes in erior to the ear along the retroauricular hair line, travels in eriorly parallel to the anterior border o the
trapezius, crosses the clavicle at the deltopectoral groove, and then can be extended a variable distance in eriorly.
See Figure 55-7.
Defect
Figure 55-7 Cervicopectoral ap.

In what layer is the dissection o cervicopectoral aps carried out?
Subcutaneously in the ace, subplatysmal in the neck, and deep to the anterior pectoral ascia on the chest.

What is the upper limit o de ects that can be reliably covered by cervicopectoral aps?
Cervicopectoral aps extending signi cantly above a line drawn between the tragus and oral commissure have
increasing risk o necrosis. However, coverage o total cheek de ects with extended cervicopectoral aps has been
described.

What is the blood supply to the deltopectoral ap?
Internal mammary artery and thoracoacromial artery (pectoral branch). T ough not described as such when
published by Bakamjian, the deltopectoral ap was one o the rst axial (nonrandom) aps.

Describe the internal mammary artery per orator (IMAP) ap?
T e IMAP is an islandized variation on the deltopectoral ap based on only one internal mammary artery
per orator. It provides thin, well-vascularized, and reliable tissue with a wide arc o rotation or coverage o
cutaneous neck, pharyngeal, and tracheostomal de ects.

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What is the blood supply to the temporalis muscle ap?
T e temporalis muscle is supplied by the anterior and posterior deep temporal branches o the internal maxillary
artery, as well as the middle temporal artery—a branch o the super cial temporal artery. T e temporalis muscle
ap is based on the anterior and posterior deep temporal branches.

What are some indications or the temporalis muscle ap in head and neck reconstruction?
As a turnover ap, the temporalis can be used as intraoral lining or the posterior oral cavity or the nasopharynx, as
well as coverage o the orbit, superior maxilla, and ear.

What are two ways to increase the pedicle length o the temporalis muscle ap?
1. emporary removal o the zygomatic arch.
2. Disinsertion o the temporalis muscle rom the coronoid process.

What is the blood supply to the sternocleidomastoid muscle ap?
T e sternocleidomastoid (SCM) muscle is supplied by branches rom the suprascapular, occipital, and superior
thyroid arteries. T e SCM ap can be based on either the occipital or suprascapular arteries, but it is relatively
un avorable or transposition because o its segmental blood supply (Mathes-Nahai ype IV, similar to the
sartorius muscle).

What is the blood supply to the platysma turnover ap?
T e platysma is a type II muscle supplied by the submental, superior thyroid, and transverse cervical arteries. T e
platysma musculocutaneous turnover ap is based on the submental artery.

What are the indications or the platysma turnover ap?
Intraoral lining, lip, and lower mid ace reconstruction.

What is the vascular supply to the trapezius muscle?
T e trapezius has three portions: the upper, middle or transverse, and lower. T e upper portion is supplied by
the occipital artery. T e middle or transverse portion is supplied by the super cial cervical artery, a branch o the
transverse cervical artery. T e lower portion is supplied by the deep branch o the transverse cervical artery (o ten
re erred to as the dorsal scapular artery) and intercostal vessels. T e origin o the arteries supplying the trapezius
muscle is highly variable, arising rom di erent vascular trunks.

What are the indications or a pedicled lower trapezius ap?
T e lower trapezius ap is typically used to reconstruct posterior cervical and occipital de ects. When based on the
super cial cervical artery, the large arc o rotation permits the ap to reach as ar as the orbit, but requires division
o the middle and upper trapezius. In contrast, when based on the deep branch o the transverse cervical artery the
arc o rotation is more limited; however, the musculocutaneous island can be planned more distally on the back.

Which ree aps are commonly used in cheek reconstruction? How could you make your own ree ap or
cheek coverage?
T in donor sites, such as radial orearm, scapular, parascapular, and anterolateral thigh are commonly used in
cheek reconstruction. For very large recipients sites (e.g., total acial burn), a tissue-expanded ree ap (with or
without pre abrication) can be used.

CHAPTER 55 Local and Regional Flaps or Head and Neck Reconstruction
549
SCALP AND FOREHEAD RECONSTRUCTION

What are the layers o the scalp?
Easy pneumonic is “SCALP”: Skin, subcutaneous Connective tissue, Galea Aponeurotica, Loose areolar tissue,
and Pericranium.

What is the blood supply to the scalp?
T ere are ve paired arteries to the scalp:
1. Supraorbital artery rom the internal carotid artery (ICA)
2. Supratrochlear artery rom ICA
3. Super cial temporal artery rom the external carotid artery (ECA)
4. Occipital artery rom ECA
5. Posterior auricular artery rom ECA

How many vessels are necessary or scalp survival?
Replantation with survival o the entire scalp has been per ormed based on a single vessel. T is is more likely to be
possible with the dominant vessels (super cial temporal and occipital) than the posterior auricular artery.

In what layer does the rontal branch o the acial nerve run?
T e rontal branch runs within the super cial temporal ascia, into the rontalis muscle just above the orbital rim.

What else is the galea aponeurotica continuous with, outside the scalp and orehead?
T e temporoparietal ascia or super cial temporal ascia laterally, and the SMAS in the ace.

Which anatomic layers are a continuation o the calvarial periosteum outside the scalp and orehead?
T e deep temporal ascia, which separates into super cial and deep layers at the temporal usion line and envelops
the super cial temporal at pad.

T e orehead and scalp are o ten considered together in reconstruction due to their similarities. What are the
two major di erences?
1. T e scalp is hair bearing.
2. T e rontalis muscle in the orehead is continuous with the galea and occipitalis muscle in the scalp.

What size orehead de ects can be e ectively closed by local aps?
For de ects up to 3 cm in diameter, options include direct closure or local aps such as rhomboid, banner, bilobed,
V-Y, A- /O- , and shutter aps.

How can additional length be gained in direct closure or local aps o the orehead and scalp?
Flap length can be extended a small amount by scoring the galea perpendicular to the axis o the ap at 5- to
10-mm intervals.

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What is the Orticochea scalp reconstruction technique?
In the pre- ree ap era, the Orticochea technique was the best option or very large scalp de ects. Utilizing either
3 or 4 extensive aps, Orticochea himsel described it as “peeling a banana” and then recon guring such that the
de ect was closed.

How should rotation-advancement scalp aps be designed?
Moderate-sized de ects o the scalp up to 9 cm can be closed with adequately designed rotation-advancement aps.
1. Attempt to design the ap so that both primary and secondary de ects can be closed directly; this may not be
possible with de ects larger than 6 cm.
2. Incorporate at least one major vessel in the ap.
3. Keep the ap base as wide as possible.
4. Flap length should be at least ve times the diameter o the de ect.
5. Bevel the incision in the direction o hair ollicles to prevent incisional alopecia.
6. Score galea as needed to gain additional length; make back cuts conservatively.

What local aps provide the best aesthetic results or small- and moderate-sized orehead de ects?
Bipedicled H aps, A-to- and O-to- aps, and V-to-Y aps. Rotational-advancement aps can be designed
with incisions along the hairline and superior eyebrow border.

What options are available or de ects larger than 6 cm in which the rotation-advancement ap donor site
likely cannot be closed directly?
Skin gra ting is possible or de ects with intact pericranium, or when bone has been prepared with burring or
removal o the outer table. issue expansion can also provide tissue or closure o moderate-sized de ects. T ese
options may not be viable in irradiated scalp tissue, in which case ree tissue trans er may be necessary even or
moderate-sized de ects.

Which ree ap is most commonly used in scalp reconstruction and why?
T e most commonly used ap is a latissimus dorsi, raised either as a musculocutaneous ap or more commonly as
a muscle ap with split-thickness skin gra t coverage. T is ap has a large sur ace area and is very thin; or men the
skin gra t can appear quite natural, and or women the thin ap acilitates wearing a wig.

What is the Crane principle?
emporary coverage o a orehead de ect with a scalp ap to regenerate adequate subcutaneous tissue or skin
gra ting. In a second stage, the ap is returned to its donor site, and a skin gra t is placed on the new subcutaneous
tissue o the original de ect.
REFERENCES
Austen WG Jr, Parrett BM, aghinia A, Wol ort SF, Upton J. T e subcutaneous cervico acial ap revisited. Ann Plast Surg. 2009;
62(2):149–153.
Buncke HJ, Rose EH, Brownstein MJ, Chater NL. Success ul replantation o two avulsed scalps by microvascular anastomoses. Plast
Reconstr Surg. 1978;61(5):666–672.

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551
Burget GC, Menick FJ. T e subunit principle in nasal reconstruction. Plast Reconst Surg. 1985;76(2):239–247.
Crosby MA. Nasal reconstruction. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing; 2007:
295–306.
Davies JC, Agur AM, Fatah AY. Anatomic landmarks or localization o the branches o the acial nerve. Clin Anatomy. 2013;1(4):
33–40.
Gosman, AA. Basics o aps. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing; 2007:20–38.
Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503–1504.
Guo L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local aps: a simple algorithm or management o small de ects. Plast Reconstr
Surg. 2008;122(5):130e–139e.
Haas F, Weiglein A, Schwarzl F, Scharnagl E. T e lower trapezius musculocutaneous ap rom pedicled to ree ap: anatomical basis and
clinical applications based on the dorsal scapular artery. Plast Reconstr Surg. 2004;113(6):1580–1590.
Heni ord BW, Bailin PL, Marsico RE Jr. Field guide to local aps. Dermatol Clin. 1998;16(1):65–74.
Hong RW, Menick FJ. Nasal reconstruction. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA: Mosby-Elsevier;
2010:381–387.
Jackson I . Local aps or acial coverage. In: Mathes SJ, ed. Plastic Surgery. Vol 5. 2nd ed. Philadelphia, PA: Saunders-Elsevier;
2006:345–390.
Kierner AC, Aigner M, Zelenka I, Riedl G, Burian M. T e blood supply o the sternocleidomastoid muscle and its clinical implications.
Arch Surg. 1999;134(2):144–147.
Leedy JE. Scalp and calvarial reconstruction. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing;
2007:279–286.
Lenert JJ, Evans GRD. Oral cavity reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders-Elsevier;
2006:917–955.
Lesavoy MA, Smith AD. Lower third ace and lip reconstruction. In: Mathes SJ, ed. Plastic Surgery. Vol 1. 2nd ed. Philadelphia, PA:
Saunders-Elsevier; 2006:799–857.
Mankani MH, Mathes SJ. Forehead reconstruction. In: Mathes SJ, ed. Plastic Surgery. Vol 1. 2nd ed. Philadelphia, PA: Saunders-
Elsevier, 2006:699–731.
Mankani MH, Mathes SJ. Forehead reconstruction. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA: Mosby-
Elsevier; 2010:373–380.
Mathes DW, Garcia CA. Cheek reconstruction. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing;
2007:307–313.
Mathes SJ, Hansen SL. Flap classi cation and applications. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia; PA: Saunders-
Elsevier; 2006:365–481.
McConnell MP, Evans GRD. Local aps o the head and neck. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA:
Mosby-Elsevier; 2010:363–372.
Menick FJ. Reconstruction o the cheek. Plast Reconstr Surg. 2001;108(2):496–505.
Mosser SW. Lip reconstruction. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing; 2007:324–336.
Orticochea M. Four ap scalp reconstruction technique. Br J Plast Surg. 1967;20:159–171.
Pribaz JJ, Chester CH, Barrall D . T e extended V-Y ap. Plast Reconstr Surg. 1992;90(2):275–280.
Pribaz JJ, Meara JG, Wright S, Smith JD, Stephens W, Breuing KH. Lip and vermilion reconstruction with the acial artery
musculomucosal ap. Plast Reconstr Surg. 2000;105(3):864–872.
Sati S, Makki AS, Shashikant M, Ramasastry SS. Scalp reconstruction. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia,
PA: Mosby-Elsevier; 2010:422–426.
Seki J . Lip reconstruction. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA: Mosby-Elsevier; 2010:401–408.
Shah AM, Jung H, Skirboll S. Materials used in cranioplasty: a history and analysis. Neurosurg Focus. 2014;36(4):E19.
Stevens CR, an L, Kassir R, Calhoun K. Biomechanics o A-to- ap design. Laryngoscope. 1999;109(1):113–117.
aghinia AH, Movassaghi K, Wang AX, Pribaz JJ. Reconstruction o the upper aerodigestive tract with the submental artery ap. Plast
Reconstr Surg. 2009;123(2):562–570.
Weinzweig J, Weinzweig N. echniques and geometry o wound repair. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia,
PA: Mosby-Elsevier; 2010:8–14.
Wells MD. Scalp reconstruction. In: Mathes SJ, ed. Plastic Surgery. Vol 1. 2nd ed. Philadelphia, PA: Saunders-Elsevier; 2006:607–631.
Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104(1):208–214.

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Wol e SA, Rivas- orres M , Ozerdem O. Reconstruction o the periorbital adnexa. In: Mathes SJ, ed. Plastic Surgery. Vol 1. 2nd ed.
Philadelphia, PA: Saunders-Elsevier; 2006:733–761.
Xue CY, Li L, Guo LL, Li JH, Xing X. T e bilobed ap or reconstruction o distal nasal de ect in Asians. Aesthetic Plast Surg. 2009;
33(4):600–604.
Younai SS, Seckel BR. Surgical anatomy o the acial nerve. In: Weinzweig J, ed. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA: Mosby-
Elsevier; 2010:427–430.
Yu P, Roblin P, Chevray P. Internal mammary artery per orator (IMAP) ap or tracheostoma reconstruction. Head Neck. 2006;28(8):
723–729.
Zavod MB, Zavod MB, Goldman GD. T e dorsal nasal ap. Dermatol Clin. 2005;23(1):73–85, vi.

INTEGUMENT
Section V

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Marissa Heller, MD
BENIGN MELANOCYTIC LESIONS

What is a nevus?
A cutaneous hamartoma or benign proli eration o cells. Usually re ers to a melanocytic nevus.

What are the three histologic types o melanocytic nevi?
Junctional, compound, and intradermal.

True/False: Melanocytes develop rom neural crest cells.
rue.

During etal development neural crest cells migrate to what eventual location?
Epidermal side o the dermal–epidermal junction.

What is a blue nevus?
A deep dermal accumulation o melanocytic cells. Its deep dermal location gives a blue, gray, or black appearance.

Can blue nevi become malignant?
Yes, rarely.

What is a Spitz nevus?
A melanocytic nevus that occurs most commonly in children.

Where does a Spitz nevus appear?
Usually presents as a small pink nodule on the ace or lower extremities. Histologically composed o pleomorphic
and cytologically atypical cells, sometimes con used or a melanoma.
Benign Skin Lesions
CHAPTER 56

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Is the risk o malignancy within a congenital melanocytic nevus (CMN) related to size?
Yes.

When is the risk o malignant trans ormation o a CMN greatest in childhood?
Usually be ore age 9.

What is a Becker nevus?
Area o hyperpigmentation and hypertrichosis, most commonly ound on the upper back, shoulder, or chest in
males. Usually presents at puberty.

What is the recommended treatment or an atypical or dysplastic nevus?
Excision with 2-mm margins.

What is a nevus o Ota?
It is a blue to gray hyperpigmentation o the skin, mucosa, or conjunctiva in the distribution o the trigeminal
nerve.

What is a nevus o Ito?
Similar in appearance to a nevus o Ota but ound on the neck or shoulder.

What is a Mongolian spot?
Congenital hyperpigmented spot ound in the sacrococcygeal region. Usually disappears in the rst 3 to 5 years o li e.

What is a nevus spilus?
An irregularly shaped light brown macule with darkly pigmented macules or papules scattered randomly within
the lesion.

What is a labial lentigo?
Hyperpigmented macule that develops on the lip, usually in young women.

Which autosomal-dominant syndrome consists o multiple lentigines and gastrointestinal polyps?
Peutz-Jeghers syndrome.

What is a halo nevus?
A melanocytic nevus with surrounding depigmentation. T is is most requent on the trunk o teenagers.
BENIGN VASCULAR LESIONS

What is the most common vascular neoplasm o childhood?
Hemangioma.

CHAPTER 56 Benign Skin Lesions
557

What is a hemangioma?
It is a benign tumor o vascular endothelium. Presents at age 4 to 8 weeks.

What is the natural history o a hemangioma?
T e lesion proli erates or the rst 6 months to a year, and then goes through involution (regression). Classically,
50% completely regress by age 5.

What is the most common complication o hemangiomas?
Ulceration.

What are complications a ter regression o a hemangioma?
Hypopigmentation, telangiectasia, excess skin, bro atty deposits, and scarring a ter ulceration.

What is a port-wine stain?
A capillary mal ormation presents at birth that grows proportionate to the patient and has normal endothelial
turnover.

What laser is used to treat a port-wine stain? Why?
Pulsed dye. Wavelength (585 nm) speci c or absorption o oxyhemoglobin with an extremely short duration
(400 ms). T e short duration limits heating o adjacent tissues.

When a acial port-wine stain is seen with leptomeningeal angiomatosis, what is it called?
Sturge–Weber syndrome.

Where does the port-wine stain occur most commonly in Sturge–Weber syndrome?
T e cutaneous areas innervated by CN V1 and V2.

Regular ophthalmologic examinations are important or which patients with port-wine stains?
All patients with V1 acial distribution.

What are blue-black hyperkeratotic vascular papules?
Angiokeratomas.

Who gets cherry angiomas?
Middle-aged and elderly patients.

What occurs in an extremity as a pain ul, purple nodule? (Hint: sometimes seen in the ngertip.)
Glomus tumor.

True/False: A condition with inherited multiple glomus tumors is transmitted in an autosomal-dominant manner.
rue.

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What syndrome has telangiectasias on the ace, lips, tongue, ears, hands, eet, GI, GU, pulmonary, CNS,
and liver?
Osler–Weber–Rendu syndrome (Hereditary hemorrhagic telangiectasia).

What are the common causes o acial telangiectasias?
Chronic UV light, rosacea, connective tissue disease, abuse o potent topical steroids, and radiation.

True/False: Pyogenic granulomas o ten develop as rapidly growing bleeding papules during pregnancy
(see Fig. 56-1)?
rue.
Figure 56-1 Pyogenic granuloma.

What is PHACE syndrome?
P (posterior ossa abnormalities), H (hemangiomas), A (arterial lesions), C (coarctation o the aorta/cardiac
mal ormations), E (eye abnormalities).

Which syndrome has a capillary mal ormation o the lower extremity associated with so t-tissue
hypertrophy, lymphedema, and venous mal ormations?
Klippel– renaunay syndrome (Angio-osteohypertrophy syndrome).
BENIGN FIBROUS AND INFLAMMATORY LESIONS

What is a solitary, rm, hyperkeratotic, sometimes pedunculated papule requently ound on the digits
overlying an IP joint, but can be ound anywhere on the hands or eet?
Acquired digital brokeratoma.

What is a lesion that is skin colored or red ound on the lateral or dorsal sur ace o a digit on an in ant or
young child?
In antile digital bromatosis.

CHAPTER 56 Benign Skin Lesions
559

What are common pedunculated papules that are o ten ound in intertriginous olds?
Acrochordons (or skin tags, or broepithelial polyps).

What is a esh-colored, pedunculated papule that can be ound anywhere on the body and what autosomal-
dominant syndrome it is associated with?
Neuro bromas are ound in neuro bromatosis or Von Recklinghausen disease.

What is a rm nodule or papule o ten ound on the extremities (see Fig. 56-2)?
Dermato broma.
Figure 56-2 Dermato broma.

What is a rm tender nodule that may have rolled borders and central ulceration and can mimic a malignant
cutaneous neoplasm?
Chondrodermatitis nodularis helicis.

What is the most common treatment modality or keloids?
Intralesional corticosteroid injections.

What are the most common side ef ects o this treatment or keloids?
Dermal atrophy and hypopigmentation.

What is the most common malignant tumor that can arise in a nevus sebaceous?
Basal cell carcinoma.

Which reddish-brown lesion exhibits Darier’s sign (urticates upon stroking)?
Cutaneous mastocytoma.

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BENIGN PREMALIGNANT LESIONS

True/False: Seborrheic keratoses are premalignant lesions.
False.

Cutaneous horns are related to what premalignant skin lesion?
Actinic keratoses.

Name the acceptable treatment modalities or actinic keratoses.
Excision, curettage, cryosurgery, dermabrasion, chemical peels, topical 5-FU, and laser ablation.

What is an eczematous condition o the nipple and areola with or without an underlying mass?
Paget disease.

What is actinic cheilitis?
A scaly, ssured, eroded lesion on the lower lip with is secondary to chronic ultraviolet light exposure. Squamous
cell carcinoma can develop rom this condition.

Which human papillomavirus (HPV) subtypes, ound in some condyloma acuminata, are considered high
risk and are associated with cancer?
HPV 16 and 18.
BENIGN SUBCUTANEOUS LESIONS

What are the most common subcutaneous so t-tissue tumors?
Lipomas.

What are the two most common types o keratinous cysts?
Epidermal inclusion cysts (o ten incorrectly termed “sebaceous cysts”), and pilar or trichilemmal cysts.

Where are pilar cysts most commonly ound?
Scalp.

What is the etiology o dermoid cysts?
Improper embryonic epithelium growth at usion sites during cranio acial development.

What are angiolipomas?
Pain ul subcutaneous nodules which are otherwise similar to lipomas.

What are the cutaneous ndings in Gardner syndrome?
Epidermal inclusion cysts, osteomas, bromas, lipomas, leiomyomas, desmoid tumors, and brosarcomas.

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REFERENCES
Giandoni MB. Fibrous tumors o the skin. In: Fitzpatrick JE, Aeling JL. Dermatology Secrets. 1st ed. Philadelphia, PA: Hanley & Bel us;
1996:278–283.
Grevelink SV, Mulliken JB. Vascular anomalies and tumors o skin and subcutaneous tissues. In: Freedberg IM, Eisen AZ, Wolf K,
et al., eds. Fitzpatrick’s Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:1002–1019.
Grichnik JM, Rhodes AR, Sober AJ. Benign hyperplasias and neoplasias o melanocytes. In: Freedberg IM, Eisen AZ, Wolf K, et al.,
eds. Fitzpatrick’s Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:881–905.
Kint A, Baran R, De Keyser H. Acquired (digital) brokeratomas. J Am Acad Dermatol. 1985;12:816–821.
Morelli JG. Vascular neoplasms. In: Fitzpatrick JE, Aeling JL, eds. Dermatology Secrets. 1st ed. Philadelphia, PA: Hanley & Bel us; 1996:
275–277.
Morelli JG, an O , Yohn JJ, Weston WL. reatment o ulcerated hemangiomas in in ancy. Arch Pediatr Adoescl Med. 1994;148:
1104–1105.
Netscher D, Spira M, Cohen V. Benign and premalignant skin conditions. In: Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic
Surgery Indications, Operations, and Outcomes. 1st ed. St. Louis, MO: Mosby; 2000:293–314.
Skohler S. Muscle, adipose and cartilage neoplasms. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St Louis, MO:
Mosby; 2008:1831–1844.
Stone MS. Cysts. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St Louis, MO: Mosby; 2008:1681–1691.
sao H, Sober AJ. Atypical melanocytic nevi. In: Freedberg IM, Eisen AZ, Wolf K, et al., eds. Fitzpatrick’s Dermatology in General
Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:906–916.
Walsh P. Benign melanocytic tumors. In: Fitzpatrick JE, Aeling JL, eds. Dermatology Secrets. 1st ed. Philadelphia, PA: Hanley & Bel us;
1996:269–274.

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Kristina Liu, MD and
Daihung Do, MD

How common is skin cancer in the United States?
T ere are currently approximately 3.5 million new cases o skin cancer in the United States annually making skin
cancer the most common type o cancer. T e incidence rate has increased dramatically over the past two decades.
Sharply increased skin cancer rates have been reported worldwide.

What are the two most common types o skin cancer?
Basal cell carcinoma (BCC) is the most common type o skin cancer. It accounts or 75% to 80% o all skin cancers
making BCC the most common type o cancer in humans. Squamous cell carcinoma (SCC) is the second most
common type o skin cancer. ogether, BCC and SCC account or 95% o all nonmelanoma skin cancers (NMSCs).

How does skin pigmentation a ect risk or skin cancer?
Lightly pigmented patients are 70 times more likely to develop NMSC than patients with darkly pigmented
skin. BCC is the most common type o skin cancer in Caucasians. In patients with a dark skin type, SCC is more
common than BCC and tends to occur in non–sun-exposed sites. In contrast, BCC tends to occur in sun-exposed
areas in dark-skinned patients with lighter complexions.

How does ultraviolet radiation contribute to carcinogenicity?
Ultraviolet (UV) light leads to the ormation o pyrimidine dimers. UVB (315–290 nm) is regarded as the most
carcinogenic ultraviolet radiation by causing direct damage to DNA and DNA repair mechanisms. UVA
(400–315 nm) is now considered to be a co-carcinogen because it potentiates the e ects o UVB.
BASAL CELL CARCINOMA

What are the risk actors or developing BCC?
T e most common risk actor is UV light exposure. Patients with air skin and little melanin are more likely to
develop BCC. T e incidence o BCC rises with decreasing latitude (closer to the equator). UV exposure rom
tanning beds and PUVA (therapeutic UV exposure) also predisposes to the development o BCC. Intermittent sun
overexposure (sunburns) early in li e (childhood and adolescence) is linked with the development o BCC. Other
risk actors are less common such as ionizing radiation, arsenic exposure, topical nitrogen mustard use, and certain
genetic syndromes.
Malignant Skin Lesions
(Basal Cell and Squamous
Cell Carcinoma)
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What inherited conditions predispose to basal cell carcinoma and other skin cancers?
• Basal cell nevus syndrome
• Xeroderma pigmentosum
• Albinism

Other than sun-exposed sites, what are the classic locations or the development o BCC?
BCC has a predilection or developing in certain locations. T ey may develop in an old scar (e.g., vaccination
scar), in thermal burns, or at the site o a nevus sebaceous.

What are some o the clinical types o BCC?
• Superf cial BCCs present as a pink to red, slightly scaly plaque. T ere may be areas o skin atrophy and
hypopigmentation present within the plaque. Occasionally, they may develop signi cant subclinical spread.
• Nodular BCC presents as a skin-colored to pink papule or plaque. It may be translucent in color leading to
their classic description as “pearly.” T e border is o ten heaped and there are typically overlying telangiectases
that may require magni cation to visualize.
• Ulcerative BCC presents as an ulcer. It usually develops rom a nodular BCC that over the course o time
has become so invasive with central necrosis that an ulcer has ormed. T ey are o ten long standing and have
a heaped pearly rim with telangiectases. When an ulcerative BCC becomes extensive and invades deeply and
widely, it may be re erred to as a rodent ulcer because the tissue appears to have been gnawed by a rat.
• Pigmented BCC presents as a dark papule and more commonly as a dark plaque. T e pigmentation may be
uni orm across the lesion or it may be ocal. T is type o BCC is o ten mistaken or a nevus, melanoma, or solar
lentigo.
• Morphea orm BCC presents as a hypopigmented shiny plaque that resembles the lesions o morphea.
Overlying telangiectases may be present. T ere is o ten extensive subclinical spread with a high risk o
recurrence.

What are the treatment options or BCC?
Curettage and electrodessication, excision, cryotherapy, photodynamic therapy, imiquimod cream, 5- uorouracil
cream, and Vismodegib.

What are the contraindications or curettage and electrodessication?
• Aggressive histologic subtypes that curette poorly such as morphea orm BCC, sclerosing BCC, in ltrative BCC,
recurrent BCC, and micronodular BCC.
• Anatomic areas rich in pilosebaceous units such as the nose and scalp. In these areas, BCC can hide between
hair ollicles.
• Deeply invasive tumors. Once the tumor has invaded through the dermis, it cannot be removed through curettage.
• Areas with so t skin texture such as the eyelid and lip. In these areas, curettage is more dif cult to per orm and
normal skin is likely to be removed with curettage.

CHAPTER 57 Malignant Skin Lesions (Basal Cell and Squamous Cell Carcinoma)
565

What is Mohs surgery?
Mohs surgery is a tissue-sparing microscopically controlled technique o excising skin cancers pioneered by
Dr. Frederick Mohs. It is o ten contrasted with routine surgical excision or surgical excision with rozen-section
analysis. In the latter technique, conventional histologic analysis o elliptical tissue specimens uses the “breadloa ”
technique in which serial transverse sections are examined, which covers less than 0.1% o the true surgical
margin. In Mohs surgery, saucer-shaped specimens are removed and processed with tangential sectioning that
allows 100% o the true surgical margin to be assessed. Specimen orientation is meticulously tracked during this
process so that residual tumor at the specimen margin can be mapped back to the patient or additional tissue
removal. In this manner, tumors can be removed with a minimal margin o normal tissue. With its high technical
precision, Mohs surgery has been shown to o er high cure rates or highly aggressive tumors in critical and
sensitive anatomic locations while o ering maximum tissue preservation.

What are the indications or Mohs surgery?
Mohs surgery is indicated when there is a high risk or local recurrence or when tissue conservation is highly desirable.
• Recurrent tumors.
• umor size > 2 cm.
• umors in high-risk locations such as the H-zone o the ace, hands/ eet, and genitalia.
• Aggressive histologic subtypes such as in ltrative, morphea orm, micronodular, metatypical BCC.
• Indistinct tumor margins.
SQUAMOUS CELL CARCINOMA

What are the risk actors or developing SCC?
• UV light exposure: air skin, chronic cumulative UV exposure, geographic location closer to the equator, PUVA
therapy
• Immunosuppression
• History o prior NMSC
• Genodermatoses
• Chronic scarring or in ammatory conditions
• Human papilloma virus in ection
• Chemical carcinogens:
• Polycyclic aromatic hydrocarbons such as soot, pitch, tar, shale oil, and mineral oil
• Arsenic
• Ionizing radiation

What is the precursor to cutaneous SCC?
Actinic keratoses (AK) are characterized by their rough texture (“gritty”), erythematous base, and ill-de ned
border. Hypertrophic actinic keratoses may be dif cult to distinguish clinically rom SCC.

What is the treatment or actinic keratoses?
Actinic keratoses are usually treated with cryosurgery. Field treatment or large numbers o actinic keratoses
includes ingenol mebutate, imiquimod, topical 5-FU, and photodynamic therapy.