Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

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Who described the anterolateral thigh ap?
Song et al. described it as a septocutaneous per orator ap in 1984.

What is the source artery o the ALT per orator ap?
Septocutaneous or musculocutaneous per orators derived rom the descending, oblique or transverse branch o
lateral circum ex emoral system.

What is the landmark or the per orators in the anterolateral thigh region?
A line is drawn rom anterior superior iliac spine to the lateral border o the patella and the per orators are usually
located in a circle 3 cm around the midpoint o this line.

What is the ratio o septocutaneous versus myocutaneous per orators in the anterolateral thigh per orator ap?
In dif erent reported series, only 12% to 33% o the patients were reported to have septocutaneous vessels while
67% to 88% had myocutaneous per orators only.

What can be the maximum dimension o an anterolateral thigh per orator ap?
8 × 20 cm.

What are the advantages o thinning anterolateral thigh per orator aps?
1. Uni ormly thin and pliable aps become available especially or reconstruction o oral cavity, neck, hand and
ngers, axilla, orearm, and anterior tibial area, when the ap is thicker than required.
2. Avoids secondary de atting or liposuction procedure.
3. Improved sensory recovery.
4. Early range-o -motion training when used in hands and ngers and better and quicker postoperative unctional
recovery in buccal and tongue reconstruction.

What is the upper width limit o the anterolateral thigh ap that can be usually closed primarily?
Although the laxity is important or this issue, generally up to 8 cm de ect can be closed primarily.

What are the variations in the anatomy o the anterolateral thigh ap?
Variations occur in 2% o the cases.
1. Absence o any per orator to the skin.
2. Small per orator.
3. Per orator pedicle that contains an artery but no vein.
4. Artery not going with the vein side by side.

What is the technical management when anatomical variations are encountered during elevation o
anterolateral thigh ap?
1. ry to dissect a per orator rom the transverse branch in the upper thigh or use the tensor ascia lata per orator ap.
2. Use an anteromedial thigh ap or aps rom the medial thigh, such as pro unda artery per orator ap or
gracilis per orator ap.
3. Convert to AL myocutaneous ap i the skin ap is not totally detached rom the vastus lateralis (VL) muscle.
4. Shi t to the opposite thigh or other donor sites with similar ap character, such as AP ap or V-RAM or
DIEP ap.

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What are the main application areas o the anterolateral thigh ap?
Head and neck reconstruction, esophagus reconstruction, chest empyema with bronchocutaneous stula,
abdominal wall reconstruction, pelvic reconstruction, upper and lower extremity reconstruction.

How is the decision made i an anterolateral thigh per orator ap should be used pedicled or as a ree ap in
abdominal wall reconstruction?
T is depends on the location o the de ect and length o the pedicle. T e ap is raised rst without division o
the pedicle. I simple transposition is enough, microvascular anastomosis can be saved. I not, the recipient vessels
should be explored. T e most sizable recipient vessels could be the deep in erior epigastric artery and vein.

What are the advantages o using an ALT ap or head and neck reconstruction?
1. Long pedicle (12.01 ± 1.05 cm) with su cient diameter (2.0–2.5 mm)
2. Pliable and wide ap territory
3. Allows or two-team approach during tumor ablation surgery
4. Feasibility to design as either a single skin paddle or one-layer de ect reconstruction or double-skin paddle or
through-and-through de ects
5. Moderate/changeable ap thickness with traditional AL ap harvesting, thinning procedure, and the
incorporation o the VL muscle as myocutaneous ap.
6. Possibility or thinning.
7. Possibility to harvest as a chimeric ap or composite ap along with the neighboring tissues, including the
vastus lateralis muscle, ascia o the tensor ascia lata, and iliac crest or bony reconstruction.
8. Potentially sensate by including the lateral emoral cutaneous nerve.
9. Inconspicuous scar over the donor site.

What are the contraindications o the anterolateral thigh ap?
T e absolute contraindications are severe atherosclerosis, previous injury, and injury in the thigh region. Obesity is
the relative contraindication.

Describe the thigh aps according to their source artery.
1. AL ap—descending branch o the lateral emoral circum ex artery (LCFA)
2. Medial thigh ap—a branch rom the LCFA or descending branch o LCFA
3. Proximal two-thirds o lateral thigh skin—transverse branch o the LCFA
4. Skin at the medial thigh—medial emoral circum ex artery and pro unda (deep) emoral artery
5. Skin at posterolateral thigh—third or ourth per orator rom the deep emoral artery
6. In erior gluteal thigh ap—in erior gluteal artery
7. Posterior popliteal thigh ap—a branch o the popliteal artery

Compare the tensor ascia lata per orator ap and anterolateral thigh ap.
T e most remarkable dif erence is the anatomy o the vessels. T e descending branch o the LCFA that supplies
the anterolateral thigh ap runs longitudinally in the intermuscular septum between the rectus emoris and vastus
lateralis muscle, whereas the transverse or ascending branch o the FL ap runs laterally. ensor ascia lata ap
has a shorter pedicle, and the subcutaneous tissue is thicker.

CHAPTER 74 Per orator Flaps
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Which per orator aps are available or breast reconstruction?
Deep in erior epigastric per orator (DIEP) ap, thoracodorsal artery per orator ( AP) ap, superior and in erior
gluteal artery per orator ap, pro unda artery per orator ap (PAP), anterolateral thigh ap (AL ).

What is the blood supply o the DIEP ap?
Per orating vessels originating rom the deep in erior epigastric artery.

What are the advantages o DIEP ap over TRAM ap?
T e rectus abdominis muscle with ascia is preserved in DIEP ap, which results in less donor site morbidity and
shorter recovery period.

What are the contraindications or the DIEP ap?
Midline abdominal scar, previous liposuction, inadequate subcutaneous tissue, and obesity.

What are the most signif cant risk actors o at necrosis in the DIEP ap?
Radiotherapy and smoking.

What are risk actors or ap ailure in DIEP ap?
obacco use, small-sized per orators, venous congestion in contralateral lateral zone (Zone IV).

What are the indications or bilateral breast reconstruction with bilateral DIEP aps?
1. Bilateral prophylactic mastectomies.
2. T erapeutic and contralateral prophylactic mastectomies.
3. Postexplantation o bilateral implants due to rupture or capsular contractures.
4. Bilateral subcutaneous mastectomies post oreign-body injection.

Which vein is considered as a “li eboat” and spared during the harvest o DIEP ap?
T e ipsilateral and contralateral super cial in erior epigastric veins.

What are alternative per orator ap or breast reconstruction i abdominal tissue is not available and their
advantages and disadvantages?
Anterolateral thigh per orator ap: easy ap harvesting with long/sizable pedicle, with signi cant donor site scar,
T oracodorsal artery per orator ap: long and sizable pedicle but need to change position during surgery and the
volume is inadequate, Superior gluteal artery per orator ap and in erior gluteal artery per orator ap: adequate
ap volume but very di cult per orator and pedicle dissection and need to change position during surgery,
pro unda artery per orator ap: ease o ap dissection, but relatively inadequate ap volume.

What is the main indication o the traditional gluteus maximus myocutaneous ap?
Since the gluteus maximus myocutaneous ap has a thick subcutaneous layer and can be raised as a pedicled ap,
it is an excellent tool to cover large sacral midline de ects and obliterate the dead space and presents as a good
option or sacrum pressure ulcer treatments in young patients with good health status.

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What are the disadvantages o the traditional gluteal maximus myocutaneous ap?
T e exposure o the donor vessels is di cult, the vascular pedicle is short, and the ap dissection is challenging.

What are the advantages o SGAP ap over superior gluteus maximus myocutaneous ap?
T e SGAP ap provides a better intraoperative exposure and a longer vascular pedicle, the scar is well hidden
and contour de ormities are minimized. In SGAP ap, the anatomical and unctional integrity o the muscle is
preserved; there ore, exposure o any nerves or bony eminences is avoided, postoperative pain is decreased and
hospitalization period is shortened.

What are the pre erred recipient vessels in breast reconstruction with SGAP ap?
T e axillary vessels should not be used or SGAP ap in breast reconstruction since the pedicle length is o ten
insu cient to allow the ap insetting medially. T e pre erred recipient vessels are either the per orators o the
internal mammary vessels at the second or third intercostals space or the internal mammary vessels themselves
between the second to the ourth intercostal junction.

Who f rst described the use o SGAP ap in breast reconstruction?
In 1995, Allen and ucker rst reported the use o the SGAP ap in breast reconstruction.

What are the indications o SGAP ap in breast reconstruction?
SGAP ap can be used or total and partial breast reconstruction and is indicated in patients who have an athletic
body habitus or who had previous abdominal surgeries that preclude the use o ree DIEP ap, such as midline
abdominal scar, multiple abdominal surgeries, abdominoplasty.

Who f rst described the thoracodorsal artery per orator ap?
Angrigiani et al. in 1995.

What are the various compositions o the thoracodorsal artery per orator ap?
Dermoadiposal ap, a composite or chimeric ashion ap including bone or regional muscle ap or a ow-through
pattern ap.

What are the advantages o the thoracodorsal artery per orator ap over scapular and parascapular aps?
T oracodorsal artery per orator ap has a longer pedicle and a relatively thinner subcutaneous tissue.

What are the application areas o the thoracodorsal per orator ap?
Because the thoracodorsal per orator ap is a large and thin ap without hair, it can be used ef ectively or
resur acing the skin and so t-tissue de ect over the hand or thumb, pretibia, and oot, as well as a ter release o
burn scar contracture, resection o malignant skin lesions or radiation ulcers. It is also suitable o acial resur acing
in the head and neck cancer surgery and is a good option in breast reconstruction in selected patients. A pedicled
per orator ap can be designed or reconstruction o partial breast de ormity a ter radiation, and chest wall
reconstruction.
Recently, the ap has been modi ed with the use o the per orators rom its descending branch close to the
anterior axillary line. With this modi cation, the surgeons can harvest the ap without turning the patient during
surgery. It allows more e cient surgeries with two team approach and reduces operation time.

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What are the advantages o the thoracodorsal per orator ap?
Large ap size, well-hidden donor scar, a long and reliable pedicle and variable tissue compositions.

What are the disadvantages o the thoracodorsal per orator ap?
Longer operation time because o changing position i the per orators rom the transverse branch are to be used,
relatively narrow ap can be harvested with donor site primary closure comparing to the AL ap.

Describe the anatomical location o the per orators o the medial sural artery per orator ap.
Most o the per orators located 9 to 18 cm rom the popliteal crease in the medial cal area, and the numbers
range rom one to our.

What are the advantages o the medial sural artery per orator ap?
1. T in and pliable.
2. Less hair bearing.
3. Long and sizable vascular pedicle.
4. Volume can be adjusted by the inclusion o part o the gastrocnemius muscle.
5. T e plantaris tendon can be harvested at the same time or tendon repair or used as a sling.
6. T e location allows a two-team approach in head and neck reconstruction.

What are the drawbacks o medial sural artery per orator ap?
1. Donor site scar widening and contour de ormity.
2. Donor site cannot be closed primarily i the ap is greater than 5 cm in width.

Describe the anatomic location o the deep circum ex iliac per orator (DCIP) artery.
T e per orator is usually 1 to 2 cm above the iliac crest and 5 cm posterior to the anterior superior iliac crest.

How is the skin paddle o the DCIP ap designed?
T e skin paddle is designed over the per orator and centered at the longitudinal axis o the upper border o the
anterior part o the iliac crest.

What are the advantages o DCIP ap over standard iliac crest osseocutaneous ap?
1. Easier contouring.
2. Eliminates the need or secondary debulking procedure.
3. Minimal sacri ce o the abdominal muscles and reduced the donor site morbidity.

Describe the anatomic location o the medial plantar per orator vessels.
T e medial plantar system emerges through the septum between the abductor hallucis muscle and the exor
digitorum brevis and sends several per orators through this intermuscular septum into the medial plantar skin.

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What are the main application areas o the medial plantar per orator ap?
T e ap provides thick, glabrous skin and is especially suitable or the repair o a nger pulp, volar sur aces o the
digits, palm or oot plantar de ects.

Describe the anatomical location and ap design o an SCIA ap?
Be ore surgery, a line connecting the anterior superior iliac supine and groin crease is made. T e super cial
circum ex iliac artery gives per orators along this line. Usually multiple per orators can be identi ed.

What are the advantages o SCIA ap?
A concealed donor site scar is obtained. Basically, all the per orators are septocutaneous without the requirement
o intramuscular ap dissection. T e ap is thin and hairless, suitable or recipient sites requiring thin ap or
reconstruction.

What are the disadvantages o SCIA ap?
Small pedicle vascular size, moderate pedicle length.

Propose clinical applications o SCIA ap?
Dorsal oot reconstruction, lower leg de ect reconstruction, and hemi-tongue reconstruction.

Describe the anatomical eature and ap design o the pro unda artery per orator (PAP) ap
T e PAP ap is nourished by per orators rom the pro unda emoral artery. Pro unda artery gives our branches
a ter the lateral and medial circum ex artery. T e rst and second branches give per orators supplying the
asciocutaneous tissue o the posterior medial thigh. T e per orators pass through the adductor magnus muscle or
the intermuscular septum between the gracilis muscle and adductor magnus muscle as septocutaneous branches.
Be ore surgery, the gracilis muscle is marked and per orators can be mapped with handheld Doppler rom the
intermuscular septum or adductor magnus muscle.

What are the advantages o the PAP ap?
T e PAP ap locates medial thigh, giving a well-concealed scar. T e ap is so t with abundant tissue. Multiple
per orators are available, giving the possibility o chimeric ap design or harvesting multiple independent aps at
the same time.

Propose clinical applications o the PAP ap.
Breast reconstruction, pedicle PAP ap or perineal reconstruction, so t-tissue reconstruction, such as head and
neck, extremities.

Propose per orator-based ree aps or one-stage repair o an ischemic f nger with pulp de ect.
Free medial plantar per orator ap, ree per orator-based ulnar orearm ap.

CHAPTER 74 Per orator Flaps
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What are the advantages o the medial plantar per orator ap?
1. Minimal donor site morbidity.
2. Possibility o primary de atting.
3. Availability o two venous drainage systems (concomitant and cutaneous venous systems).
4. Good color and texture match with the nger skin.
5. Concealed location o the donor site.
6. Ease in ap elevation.

Where is the most common location o per orators o the IMA per orator?
T e largest and most commonly ound internal mammary artery per orator has been reported to be in the second
and third intercostal spaces.

What is the vascular pedicle o the IMA per orator ap?
Internal mammary artery and vein.

What is the advantage o the IMA per orator ap?
1. Freedom o arc o rotation to the chest wall and neck.
2. Reliable blood supply rom the internal mammary vessels.
3. Similar skin texture and color to the neck.
4. Primary closure o donor site.
5. Being able to preserve the pectoralis muscle myocutaneous ap or urther application in repeated recurrent
head and neck cancer reconstruction.

What is a chimeric ap?
A chimeric ap has separate components with separate vascular supplies that are attached to a common source
vessel, either by arti cial anastomosis or as a natural structure.

What is a per orator-based chimeric ap?
Skin paddles or dif erent tissue components can be elevated based on at least two per orators rom dif erent
vascular systems, which can be merged or anastomosed to a nal source pedicle.

What are the advantages o using a chimeric ap?
Easy three-dimensional insetting, acceptable aesthetic appearance, reduced donor site morbidity, precise ap
design, shorter operation time, and requirement o one pair o recipient vessels.

What are the disadvantages o using a chimeric ap?
T e possible variations o per orators, a learning curve, easy twisting o per orators and/or pedicle and sometimes
the need or a second venous drainage or shi ting to double aps.

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Which aps are available to be harvested as chimeric ap?
Anterolateral thigh ap, thoracodorsal artery per orator ap, medial sural artery per orator ap and pro unda
artery per orator ap

Propose a ap or one-stage reconstruction o wide and through-and-through cheek de ect involving the
oral commissure.
T e anterolateral thigh chimeric ap with vastus lateralis or volume augmentation, and tensor ascia lata or
mouth angle suspension.
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Ingrid Ganske, MD and
Bohdan Pomahac, MD
NOMENCLATURE

What is an allogra t?
issue transplantation between unrelated individuals o the same species.

What is an autogra t?
Donor tissue, such as a skin gra t, that comes rom the same patient.

What is the term or a gra t that comes rom a genetically identical donor, such as an identical twin?
Isogra t.

What is a xenogra t?
A cross species gra t, such as porcine skin gra ts used as temporary skin substitutes or porcine or bovine acellular
dermal matrices.

What is the di erence between orthotopic and heterotopic transplants?
Orthotopic transplants are trans erred into an anatomically similar site, whereas heterotopic transplants are
trans erred into a site di erent rom their origin.
HISTORY

When was the f rst human organ transplantation?
Dr. Joseph Murray per ormed the rst solid organ transplantation, a kidney, in 1954, between identical twin brothers.

What types o composite tissue allotransplantations have been per ormed?
Hand, lower extremities, ace, abdominal wall, knee, f exor tendon apparatus, nerve, larynx, skeletal muscle,
tongue, trachea, scalp, uterus, penis.
Vascular Composite
Allotransplantation
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IMMUNOLOGY

Which antigens are the most immunogenic?
Major histocompatability complex (MHC) antigens. In humans, these are human leukocyte antigens (HLAs).
HLAs reside on the sur ace o cells. HLA class I antigens are expressed on all nucleated cells, and class II antigens
are only expressed on antigen presenting cells (APCs) such as B lymphocytes, monocytes, macrophages, dendritic
cells (DCs), endothelial cells, and activated cells.

What is hyperacute rejection?
ABO incompatibility and antibody incompatibility result in hyperacute rejection, which is mediated by the
humoral immune system and occurs within minutes o transplantation.

What is acute rejection?
Acute rejection is caused by the direct pathway o allorecognition, in which donor APCs migrate to host lymphoid
tissue and activate cells. T ese cells migrate to the gra t and mediate gra t rejection. Acute rejection occurs
within weeks to months ollowing transplant, and periodically at various time points later.

What is chronic rejection?
Chronic rejection occurs months to years a ter transplantation. It is contributed to by both direct and indirect
pathways o allorecognition, although the indirect pathway is thought to be o greater signi cance in the
pathogenesis o chronic gra t rejection. In the indirect pathway, host APCs present processed donor antigens to
host cells. Intimal hypertrophy leading to lumen obliteration and ischemia are typical, as well as sclerotic skin
changes.

Which is the most common type o rejection?
Acute rejection. Chronic rejection in vascular composite allotransplantation (VCA) is just being de ned.

Which tissue type is most antigenic?
Skin and vascular endothelium is thought to be the most antigenic and immunoreactive tissue in VCA.
T e vascularized muscle component o limb allogra ts may induce a cell-mediated response greater than the skin;
however, muscle as a single component is less antigenic than skin.

Which tissue types are least antigenic?
Cartilage and tendon are the least antigenic. Bone represents lower immunogenicity than skin and muscle.

Which tissue type is best to monitor or rejection?
T e skin is also an easily monitored tissue (versus solid organs), so it is the most sensitive indicator o acute
rejection in that it is clearly visible and can be easily evaluated by both patient and physician. T ere ore, this tissue
type is most appropriate to be monitored and biopsied.

CHAPTER 75 Vascular Composite Allotransplantation
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What are the main groups o immunosuppressive medications?
1. Steroids (prednisone)
2. Cytotoxic drugs (cyclophosphamide, methotrexate, azathioprine)
3. Fungal or bacterial products (cyclosporine, tacrolimus/FK506, mycophenolate mo etil, and sirolimus)
4. Antilymphocyte and antithymoglobulin

What is the mechanism o steroids?
Steroids with anti-inf ammatory actions, such as prednisone, inhibit NF-kB transcription actor, which inhibits
cellular activation and cytokine production.

What is the mechanism o cytotoxic drugs?
Cyclophosphamide, methotrexate, and azathioprine inter ere with DNA replication and kill the proli erating
lymphocytes activated by alloantigens.

What is the mechanism o cyclosporine and FK 506?
Cyclosporine and FK506 inhibit calcineurin activation and IL-2 gene transcription, which inter eres with
-cell activation pathways. Cyclosporine is a metabolic extract rom the ungus olypocladium inf atum gamus
discovered in the 1970s that has revolutionized the eld o visceral organ transplantation and has been shown to
prolong limb allogra t survival in experimental studies. FK506 is a macrolide lactone antibiotic isolated rom soil
ungus.

What is the mechanism o mycophenolate mo etil?
It is derived rom the ungus Penicillium stoloni erum and inhibits inosine monophosphate dehydrogenase, which
is necessary or production o guanine monophosphate needed or B and lymphocyte proli eration.

Which immunosuppressive medications have not been shown to impair wound healing?
Antilymphocyte agents, such as lymphocyte immune globulin, antithymoglobulin (A G), and monoclonal
antibodies against -cell receptors such as basiliximab.

What are common side e ects o immunosuppressive medications?
Renal toxicity, blood glucose disturbances, opportunistic in ections. Skin malignancies can also occur long term.

What is tolerance?
T e speci c absence o a destructive immune response to a transplanted tissue in the absence o
immunosuppression. T e key element o this de nition is “speci c,” because the recipient must remain capable o
response to other antigens. olerance can be developed by central or peripheral mechanisms.

What is central tolerance?
In the thymus, alloreactive cells that develop in response to bone marrow–derived APC are deleted. In rodents,
deletion o cells can be induced by introducing donor antigens into the thymus by intrathymic injection. Other
studies have examined mixed hematopoietic bone marrow transplantations. T is requently involves total body
irradiation or the recipient, ollowed by donor bone marrow transplantation (deplete o donor cells) to induce
mixed chimerism.

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What is peripheral tolerance?
Mechanisms o peripheral tolerance include -cell nonresponsiveness, induction o -suppressor cells, and -cell
deletion. Monoclonal antibodies and DCs play a role in stimulating peripheral tolerance.

What are the important viral serologies to crossmatch?
Hepatitis B, hepatitis C, cytomegalovirus, Epstein–Barr virus, and human immunode ciency virus.

What is gra t-versus-host disease?
An entity occurring in bone marrow transplant patients. cells present in the gra t attack the tissues o the
recipient, perceiving the host tissues as antigenically oreign. Acute GVHD is observed in the rst 3 months; the
chronic orm is later. Clinical mani estations include damage to the liver, skin, mucosa, GI tract.
ETHICS

What are the primary ethical dilemmas with reconstructive transplantation?
Reconstructive transplantation is per ormed in healthy patients who have a normal li e expectancy, and requires
li elong immunosuppression, which induces medical issues, and may even shorten li e expectancy.

What are the specif c risk–benef t concerns with upper extremity transplantation?
Justi cations or upper extremity transplantation include both unctional and sel -image improvement.
ransplanted hands have been reported to per orm better than prosthesis; however, prosthetic technology
is a rapidly improving eld. T ere is a general consensus that bilateral amputees are good candidates or
transplantation.
In addition, chronic rejection, which is common in all organ transplants, results in brosis and potentially leads to
decreased unction in the long term.

What are specif c ethical concerns or acial allotransplantation?
rans er o appearance rom deceased donor; though a signi cant concern, we have learned that it does not occur.
Selection o patients—who is and who is not a good candidate? All recipients must undergo thorough psychiatric
prescreening.
Salvage plan in case acial allogra t loss occurs; typically this involves autologous skin gra ts or f ap reconstruction.
Salvage might leave the patient in a unctional and aesthetic state worse than pretransplantation. In addition,
donor harvest must be expedient and well-planned so that it does not impact vital organ harvest rom the same
donor.
REFERENCES
Barth RN, Rodriguez ED, Mundinger GS, et al. Vascularized bone marrow-based immunosuppression inhibits rejection o vascularized
composite allogra ts in nonhuman primates. Am J Transplant. 2011;11(7):1407–1416.
Harrison JH, Merrill JP, Murray JE. Renal homotransplantation in identical twins. Surg Forum. 1956;6:432–436.
Hui-Chou HG, Nam AJ, Rodriguez ED. Clinical acial composite tissue allotransplantation: a review o the rst our global experiences
and uture implications. Plast Reconstr Surg. 2010;125:538–546.

CHAPTER 75 Vascular Composite Allotransplantation
731
Lee WP, Yaremchuk MJ, Pan YC, Randolph MA, an CM, Weiland AJ. Relative antigenicity o components o a vascularized limb
allogra t. Plast Reconstr Surg. 1991;87(3):401–411.
Lee WPA, Butler P, Mathes D. ransplantation in plastic surgery. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. 2nd ed. Philadelphia,
PA: WB Saunders; 2006:269–292.
Madani H, Hettiaratchy S, Clarke A, Butler PE. Immunosuppression in an emerging eld o plastic reconstructive surgery: composite
tissue allotransplantation. J Plast Reconstr Aesthet Surg. 2008;61(3):245–249.
Murray JE. Organ transplantation (skin, kidney, heart) and the plastic surgeon. Plast Reconstr Surg. 1971;47(5):425–431.
Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current principles o acial allotransplantation: the Brigham and Women’s Hospital
Experience. Plast. Reconstr Surg. 2013;131:1069–1076.
Sarhane KA, Khali an S, Ibrahim Z, et al. Diagnosing skin rejection in vascularized composite allotransplantation: advances and
challenges. Clin Transplant. 2014;28(3):277–285.
Sarhane KA, u aha SH, Broyles JM, et al. A critical analysis o rejection in vascularized composite allotransplantation: clinical, cellular
and molecular aspects, current challenges, and novel concepts. Front Immunol. 2013;4:406.
Siemionow MZ, Kulahci Y, Bozkurt M. Composite tissue allotransplantation. Plast Reconstr Surg. 2009;124:e327–e329.
Silverman RP, Banks ND, Detolla LJ, et al. A heterotopic primate model or acial composite tissue transplantation. Ann Plast Surg.
2008;60(2):209–216.
Starzl E. Immunosuppressive therapy and tolerance o organ allogra ts. N Engl J Med. 2008;358(4):407–411.
Whitaker IS, Duggan EM, Alloway RR, et al. Composite tissue allotransplantation: a review o relevant immunological issues or plastic
surgeons. J Plast Reconstr Aesthet Surg. 2008;61(5):481–492.

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733
Nicole L. Nemeth, MD, FACS

What is the rst step in management o a burn victim?
Primary survey—maintain airway patency, breathing, circulation. (Just like the ABCs o any trauma.)
Secondary survey—identi y associated li e-threatening injuries and remove burned clothing and jewelry.

What are the ABA criteria or trans er to a specialized burn center?
1. Partial-thickness burns involving greater than 10% total body sur ace area ( BSA)
2. Burns that involve the ace, hands, eet, genitalia, perineum, or major joints
3. T ird-degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders that could complicate management
8. Any patients with traumatic injury in which the burn injury poses the greatest risk o morbidity or mortality
9. Any burned children i the hospital initially receiving the patient does not have quali ed personnel or
equipment or children
10. Any patient with burns that require special social, emotional, or long-term rehabilitative intervention

What methods are used to estimate burn size?
Lund and Brower chart—most accurate, accounts or body proportions by age group.
Wallace’s “Rule o Nines”—head and neck (9%), anterior torso (18%), posterior torso (18%), each upper
extremity (9%), each lower extremity (18%), and perineum (1%).
“Patient’s Palm” method—the patient’s palm is roughly equivalent to 1% o the BSA.

When should uid resuscitation begin in a burn victim?
Fluid resuscitation should begin immediately. Resuscitation or burns > 20% BSA in an adult is based on
the Parkland ormula. Resuscitation requirements are calculated based on the time o injury, not the time o
presentation.
Burn Care
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What is the Parkland ormula?
4 mL × weight (kg) × % BSA = total volume o Lactated Ringer’s (LR) to be given over the rst 24 hours.

At what rate should uid resuscitation begin or a 70-kg man with second- and third-degree scald burns to
the anterior torso and the anterior aspect o both lower extremities, now 2 hours postinjury?
T is patient has about 18% BSA to the anterior torso and 9% BSA to each anterior lower extremity
(18 + 9 + 9 = 36% BSA).
4 mL × 70 kg × 36% = 10,080 cc o LR over rst 24 hours.
Hal o volume is given over the rst 8 hours; the remainder is given over the next 16 hours.
10,080 ÷ 2 = 5,040 mL needed within the rst 8 hours.
5,040 ÷ 6 = 840 mL/hr (the total uid requirements or the rst 8 hours will be given within 6 hours since the
patient presented in a delayed ashion).

For this patient, at what rate should uid resuscitation continue over the next 16 hours?
5,040 ÷ 16 = 315 cc/hr.

At what rate should uid resuscitation begin or a 70-kg man now 24 hours a ter ash ame exposure, with
an 18% area o rst-degree burn to the posterior torso?
No uid resuscitation is instituted or rst-degree burns o any etiology.

How are the resuscitation requirements determined or children?
Based on body sur ace area:
Galveston Shriners Burns Institute ormula: 5,000 mL/m2/BSA burn + 2,000 mL/m2/total BSA = total LR or
rst 24 hours.

What is the single best monitor o uid resuscitation?
Urine output (0.5 mL/kg/hr or adults; 1.0–2 mL/kg/hr or children).

By what percent does inhalation injury increase uid resuscitation requirements?
40% to 75% (~2 cc/kg/% BSA).

What is the uid regimen or patients with myoglobinuria or hemoglobinuria?
Discontinue LR and begin normal saline with sodium bicarbonate.

What osmotic diuretic may be added to assist in clearing the urine o these pigments?
Mannitol.

Which burn patients should receive tetanus immunization?
10% BSA burn injury should receive 0.5 cc o tetanus toxoid; i unknown immunization history or > 10 years
since last booster, add 250 units o immunoglobulin.

CHAPTER 76 Burn Care
735

What are the depth classi cations o burn injury?
First degree—involves epidermis only.
Second degree—involves partial thickness o dermis.
T ird degree—involves ull thickness o dermis and all adnexal structures.
Fourth degree—involves underlying muscle, bone, or tendon.

What is the clinical appearance o a partial-thickness versus ull-thickness burn wound?
A partial-thickness wound bed usually will be pink and moist underneath blisters, with intact sensation. A
ull-thickness injury will appear dry and insensate, and may be white, leathery, or charred depending on the depth
o involvement.

In what order do di erent sensory modalities return in a healed burn wound?
Pain ( rst), light touch, temperature, vibration (last).

What are the three histologic zones o burn injury?
Zone o necrosis—area o tissue necrosis due to destruction rom burn injury.
Zone o ischemia—surrounds zones o necrosis; can convert to zone o necrosis because o inadequate tissue
per usion.
Zone o hyperemia—surrounds zone o ischemia; usually reversible injury (heals).

What intervention prevents the progression o a zone o ischemia to a zone o necrosis?
Adequate uid resuscitation with per usion o ischemic tissue.

When should escharotomies be per ormed?
For deep, circum erential extremity burns with decreased or absent pulses or deep burns involving the torso that
impair ventilation.

How should escharotomy incisions be planned?
Release o eschar should occur immediately at the bedside using a Bovie electrocautery.
Midaxial incisions release eschar o extremities.
Axial incisions along the anks that connect across the midline to release the chest/torso.
Unilateral midaxial incisions on the digits on the radial sur ace o the small nger and thumb; escharotomy
incisions on the index, long, and ring nger generally should be placed on the ulnar sur ace.

I per usion to a distal extremity does not improve a ter an escharotomy is per ormed, what is the next step
in management?
Fasciotomy.

What is the cardiovascular response to a burn injury?
Cardiac output (CO) initially decreases and systemic vascular resistance (SVR) increases.
A ter the rst 24 to 48 hours, the heart rate and CO increase and SVR decreases.

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Plastic & Reconstructive Surgery Board Review

How are red blood cells a ected by burn injury?
T eir T1/2 is shortened.

What are some causes o early renal insuf ciency in burned patients?
Hypovolemia, vasoconstriction due to catecholamine release, myoglobinuria, nephrotoxic medications.

What is the cause o Curling’s ulcer?
A decrease in splanchnic blood ow and gut motility (ileus) place burn patients at risk or Curling’s ulcer usually
involving the stomach or proximal small bowel. Appropriate prophylaxis is usually instituted to prevent mucosal
erosion.

Which muscle relaxant should be avoided in burned patients?
Succinylcholine—causes marked hyperkalemia.

What is the immunologic response to thermal injury?
Decreased lymphocytes, macrophages, immunoglobulins, and lysosomal enzymes.

What is the hypermetabolic response?
A ter an early “ebb” phase, a more prolonged period o protein catabolism, lipolysis, tachycardia, increased urinary
output, increased oxygen consumption, nitrogen loss, and elevated body temperature ensues.

What are the hormonal mani estations o the hypermetabolic response?
Increased levels o cortisol, catecholamines, and glucagons; there is an overall increase in the blood glucose level.

What are signs and symptoms o inhalation injury?
Facial burns, singed nasal hairs, carbonaceous sputum, hypoxemia with or without an elevated carbon monoxide
(CO) level, hoarseness, stridor.

What is an accurate and practical test or diagnosing an inhalation injury?
Fiberoptic bronchoscopy.

Why is the early diagnosis o inhalation injury critical?
Inhalation injury will increase the uid requirements or resuscitation, may lead to airway edema and respiratory
distress, and can signi cantly increase the risk or mortality.

How can parenchymal thermal lung injury be detected?
133Xenon lung scan.

What is CO poisoning considered the “great imitator?”
T e symptoms o CO poisoning mimic those o the u. Carboxyhemoglobin levels as low as 10% can cause
headache, dizziness, nausea, and dyspnea. Higher levels can lead to chest pain, tachycardia, seizures, loss o
conscious and death.

CHAPTER 76 Burn Care
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What is the treatment o carbon monoxide poisoning?
Hyberbaric oxygen (usually delivered at 2.5–3 atmospheres o pressure) is administered in a hyperbaric oxygen
chamber or patients with elevated carboxyhemoglobin levels upon arrival at most burn centers. In pregnant
patients, the threshold or treatment can be or levels as low as 10%, since etal hemoglobin has an higher a nity
or CO.

What is the T1/2 o carbon monoxide at room air and on 100% oxygen?
~4 hours on room air, ~45 minutes on 100% oxygen (at sea level).

What is the initial treatment o suspected inhalation injury?
100% oxygen via ace mask or nasal cannula.

What is a low-voltage versus a high-voltage electrical exposure?
Low voltage—< 1,000 volts, mostly cutaneous mani estations o burn injury.
High voltage—> 1,000 volts, extent o injury usually involves deeper structures (based on resistance o dif erent
tissues to passage o current).

How does a lightning injury di er rom a high-voltage electrical accident?
Lightning injuries result in a “ ashover” and do not tend to cause devastating internal thermal injuries.

What is the most common cause o death in a lightning victim?
Cardiopulmonary arrest.

Which tissue has the greatest amount o resistance and there ore produces the most heat?
Bone.

Which tissues have the least resistance to electrical current?
Nerves, blood vessels, muscle.

What are emergent management considerations or electrical injury?
Evaluate or associated injuries, including cervical spine or extremity ractures, pneumothorax, neurologic changes,
cardiac arrhythmias.
Escharotomy or asciotomy alone or in combination ( or compartment syndrome) and nerve decompression (e.g.,
release o Carpal tunnel, Guyon’s canal) may also be warranted emergently.

What are long-term management considerations or a patient with an electrical injury?
Debridement o all nonviable tissue, especially muscle; involved extremities may require amputation.
Cataracts may present with a slow and progressive onset years a ter the injury.

How are low-voltage electrical oral commissure burns managed?
Conservative local wound and splinting with a mouth spreader to prevent microstomia.

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Plastic & Reconstructive Surgery Board Review

What is a known complication o the use o a mouth spreader splint?
Hemorrhage rom the super cial labial artery with sloughing o the eschar (5–7 days).

What are the rst steps in management o a chemical burn?
Disrobe patient, early irrigation o af ected area with copious amounts o plain water, identi y of ending agent,
identi y and treat systemic toxicity.

Why should a chemical burn NOT be treated with a neutralizing agent?
T e heat generated can induce a thermal injury.

Which causes a deeper burn: acids or alkalis?
Alkalis.

What are some commonly encountered alkali agents?
Lime, bleach, sodium hydroxide, potassium hydroxide (usually agents ound in household cleaning products).

What are the mechanisms by which alkali chemicals induce tissue injury?
1. Fat saponi cation.
2. Water extraction rom cells.
3. Formation o hydroxide ion-containing alkaline proteinates, leading to deeper tissue penetration.

What are examples o some commonly encountered acidic agents?
Acetic acid, hydrochloric acid, hydro uoric acid (HF), trichloroacetic acid.

By what mechanisms do acid chemicals induce tissue injury?
Hydrolysis o proteins, generation o heat in contact with skin.

How does HF di er in its mechanism o injury?
Free uoride ions complex with bivalent cations (Ca+ +, Mg+ +) to orm insoluble salts, thereby depleting the
available Ca+ + and Mg+ + in circulation.

What can be applied topically to chelate uoride ions and reduce pain?
2.5% calcium gluconate in a water-soluble gel.

I pain relie is re ractory to topical calcium gluconate, what is the next step in management?
Subcutaneous injection o 10% calcium gluconate.

How are phosphorous and phosphoric acid similar to HF?
T ey bind calcium ions.

CHAPTER 76 Burn Care
739

What can be applied topically to impede oxidation and burn injury rom phosphorous compounds?
0.5% copper sul ate solution—on contact, copper sul ate orms a black lm that delineates the area o phosphorus
injury.

What is the mechanism o tissue injury rom rostbite?
T rombosis o microvasculature and extracellular ice crystal ormation causing cellular damage.

What is the initial treatment o an appendage with rostbite?
Rapid rewarming (water bath at 104–108°F) or 20 to 40 minutes until reper usion occurs.

What are other potential modalities or treatment o rostbite?
Ibupro en, intravenous heparin, thrombolytics.

How soon should surgical debridement o involved tissue be per ormed or rostbite?
A ter ull demarcation o necrosis, weeks to months later. Local wound care is the mainstay o treatment otherwise.

What is the basic tenet o surgical treatment or burn wounds?
Wounds that will not heal within 2 weeks should be excised and skin gra ted.

Which wounds tend to require excision and autogra ting?
Deep partial-thickness and ull-thickness burn wounds.

What is the “overlay” gra ting method?
T e use o widely expanded (4:1 meshed) split-thickness autogra t with a meshed, unexpanded homogra t overlay
(used or patients with large burns and minimal donor sites).

What is the most common side e ect o silver sul adiazine (Silvadene)?
ransient leukopenia.

What is the most common side e ect o ma enide acetate (Sul amylon)?
Carbonic anhydrase inhibition or hyperchloremic metabolic acidosis.

What are the side e ects o silver nitrate solution?
Electrolyte leaching, methemoglobinemia, silver discoloration o tissues.

What is Acticoat?
Antimicrobial silver-coated barrier dressing.

What is Biobrane?
Knitted nylon mesh bonded to a thin silicone membrane with a porcine collagen matrix.

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Plastic & Reconstructive Surgery Board Review

How does TransCyte compare to Biobrane?
Both are temporary skin replacement products— ransCyte has a polymer membrane with newborn human
broblasts cultured onto a porcine collagen nylon mesh.

What is Integra?
Bilaminate membrane—outer silicone layer and inner dermal layer made up o bovine type I collagen that is cross-
linked with shark glycosaminoglycans and chondroitin-6-sul ate.

What are some advantages and disadvantages o using Integra or wound closure or contracture release?
T e disadvantages are the need or a second surgery to remove the outer silicone layer, the risk o collecting uid
under the Integra, and in ection.
T e advantage is the creation o a “neodermis” and the ability to take a very thin (~0.005 in) split-thickness skin
gra t.

When should the outer silicone layer be removed?
Approximately 21 days.

How does AlloDerm di er rom allogra t?
AlloDerm is acellular cadaver skin that incorporates as a neodermis and can also be gra ted with a much thinner
skin gra t.
Allogra t is cadaveric homogra t. It is not acellular so an eventual immune response is to be expected.

What is xenogra t?
From the root word xenos (the Greek word or “ oreign”), xenogra t re ers to tissue that is transplanted rom one
species to a dif erent species. In burn care, the most commonly used xenogra t is porcine skin or temporary
wound coverage.

What is CEA?
Cultured epithelial autogra t—keratinocytes cultured in a laboratory setting over 3 to 4 weeks rom a single punch
biopsy o patient’s normal skin.
Utilized or near total 100% BSA burns that require excision and gra ting.

How is a skin gra t per used within the rst 24 to 48 hours?
By plasmatic imbibition; the gra t becomes vascularized by inosculation over a period o 3 to 4 days.

What is plasmatic imbibition?
Plasmatic imbibition is the passive transport o nutrients rom the wound bed to the gra t.

What is inosculation?
Inosculation is the establishment o anastomoses between gra t and recipient blood vessels. Revascularization is
complete by 7 days.

CHAPTER 76 Burn Care
741

What is neovascularization?
T e ingrowth o durable, new vessels into the skin gra t.

What is primary versus secondary contraction?
Primary contraction is the passive immediate recoil o a skin gra t a ter gra t harvest.
Secondary contraction is the shrinkage o the gra t that occurs during the healing process due to the action o
myo broblasts. Increasing amounts o deep dermis included in thicker gra ts are comparatively more resistant to
secondary contraction than a gra t that includes less dermis.

In what order do skin gra ts undergo increasing amounts o primary contraction?
Meshed split thickness, thin split thickness, thick split thickness, ull thickness. How do you remember this?
MORE DERMIS = MORE ELAS IN = MORE PRIMARY CON RAC ION.

What is the depth o harvest or each type o split-thickness skin gra t?
T in split-thickness skin gra t: ≈0.005 to 0.012 in thick
Medium split-thickness skin gra t: ≈0.012 to 0.018 in thick
T ick split-thickness skin gra t: ≈0.018 to 0.030 in thick

What quality o the skin gra t determines the degree o primary contraction?
Elastin present in increasing amounts with the thickness o the dermal component provides a greater potential or
primary contraction.

What is an important aspect o burn rehabilitation/reconstruction that begins during the acute phase o the
injury?
Early range o motion, mobilization, and proper positioning/splinting.

How should burned areas be splinted?
Neck in slight extension, shoulder abducted, elbow in ull extension, hand in intrinsic plus position, hips in
extension/abduction, knees in ull extension, and oot in neutral position/90 degrees o dorsi exion.

What is the best way to preserve the most normal appearance in acial burn coverage?
Using medium- or ull-thickness skin gra ts and gra ting within acial aesthetic units. Full-thickness skin gra ts
require closure at the donor site (either primary or with split-thickness skin gra ting), and tend not to be used in
the acute phase o burn coverage.

How can the reconstruction o burn alopecia be managed?
Excision and primary closure ( or small, concentrated de ects).
issue expansion (de ects up to 50% o the scalp).
Scalp rotational aps (larger de ects, with or without tissue expansion).

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Plastic & Reconstructive Surgery Board Review

What is the approach to operative management o an anterior neck contracture with lower lip and lower
eyelid ectropion?
Usually, the neck undergoes surgical release rst, ollowed by the lower lip and lower eyelids. Lower lip and lower
eyelid ectropion may improve or resolve a ter release o the anterior neck.

What is the pre erred skin gra t technique or upper versus lower eyelid ectropion reconstruction?
T e upper eyelid is released with a split-thickness skin gra t ( or mobility), whereas the lower eyelid is released with
a ull-thickness skin gra t ( or support).

What are examples o aps commonly used in burn reconstruction?
Z-plasty, V-to-Y, 5 ap plasty (also known as, “Jumping Man”).
Scalp rotational aps.
Advancement o neck and acial aps a ter tissue expansion.
Pedicled or ree tissue trans er or release o burn scar contracture (scapular/parascapular, thoracoepigastric,
anterolateral thigh, latissimus dorsi).

How can one predict the length o postexpansion tissue gain or use in an advancement ap or adjacent
wound coverage or resur acing?
T e predicted length o tissue gain can be calculated by the expander dimensions. T e advancement length is
calculated by subtracting the base diameter rom the circum erence o the ully expanded implant.

What are ex oliating “burns?”
Certain in ectious and autoimmune conditions, such as scalded skin syndrome, pemphigus vulgaris, bullous
pemphigoid, erythema multi orme, Stevens–Johnson syndrome, and toxic epidermal necrolysis, can lead to
blistering and desquamation and are o ten treated in a burn center.

How are the di erent ex oliating “burns” diagnosed and di erentiated?
Skin biopsy, clinical presentation, and history o known of ending agent or medication.
REFERENCES
Brou JA, Robson MC, McCauley RL, et al. Inventory o potential reconstructive needs in the patient with burns. J Burn Care Rehabil.
1989;10:555–560.
Hansen SL, Voigt DW, Wiebelhaus P, Paul CN. Using skin replacement products to treat burns and wounds. Adv Skin Wound Care.
2001;14(1):37–44.
Herndon D, ed. Total Burn Care. 2nd ed. London, UK: WB Saunders; 2002.
Nguyen , Gilpin DA, Meyer NA, Herndon DN. Current treatment o severely burned patients. Ann Surg. 1996;223(1):14–25.
Press B. T ermal, electrical, and chemical injuries. In: Aston SJ, Beasley RW, T orne C, eds. Grabb and Smith’s Plastic Surgery. 5th ed.
Philadelphia, PA: Lippincott-Raven; 1997:161–189.
Sheridan RL. Burns. Crit Care Med. 2002;30(11 Suppl):S500–S514.

743
William W. Dzwierzynski, MD, FACS,
Elizabeth A. O’Connor, MD, and
Jenna Cusic, MD

Identi y the anatomy o the ear (Fig. 77-1).
Ear Reconstruction
CHAPTER 77
1. Helix
2. Scapha
3. Antihelix
4. Antitragus
5. Posterior crus antihelix
6. Triangular fossa
7. Anterior crus antihelix
8. Cymba of concha
9. External auditory meatus
10. Tragus
11. Cavum of concha
12. Lobule
1
5
6
8
9
10
11
12
7
2
3
4
Figure 77-1 Anatomy o the ear.

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Plastic & Reconstructive Surgery Board Review

Which embryologic structures give rise to the ear?
T e rst two branchial arches give rise to six hillocks that orm the ear.
T e rst arch orms the malleus, incus, and anterior hillocks (1–3).
T e second arch orms the stapes and posterior hillocks (4–6).

What structures arise rom the anterior (1–3) hillocks?
T e tragus, root helix, and superior helix.

What structures arise rom the posterior (4–6) hillocks?
T e antihelix, antitragus, and lobule.

What ear structures are ormed rom the rst branchial groove?
T e external auditory canal and concha.

What is the average length o the ear?
T e average length is 6 cm. Approximately 90% o the growth occurs by 5 years o age.

What is the angle o protrusion o the ear?
25 to 30 degrees.

What is the vascular supply o the ear?
T e ear is supplied by branches o the external carotid artery:
1. T e lateral ear is supplied by the super cial temporal and posterior auricular arteries.
2. T e medial ear is supplied by the posterior auricular and posterior occipital arteries.
3. T e triangular ossa and scapha are supplied by the helical branch o the super cial temporal artery.
4. T e concha is supplied by septal per orators o the posterior auricular artery.

What is the vascular supply to the ear cartilage?
T e cartilage is an avascular structure, which is supplied by the surrounding perichondrium and so t tissue.

What is the lymphatic drainage o the ear?
T e lymphatic drainage may vary, although it generally ollows embryologic development:
1. T e superolateral ear and anterior external auditory meatus drain to the parotid nodes.
2. T e superomedial ear and posterior external auditory meatus drain to the mastoid nodes.
3. T e in erior ear and lower external auditory meatus drain to the super cial cervical nodes.
4. T e concha and meatus drain to the preauricular nodes.

CHAPTER 77 Ear Reconstruction
745

Describe the innervation o the ear.
1. T e auriculotemporal branch (V2) supplies the superolateral ear.
2. T e great auricular branch (C2–3) supplies the in erolateral and in eromedial ear.
3. T e lesser occipital branch (C2–3) supplies the superomedial ear.
4. T e auditory (“Arnold’s”) branch (X) supplies the concha and external auditory canal.

How do you anesthetize the ear?
Anesthesia o the ear, except the concha and external auditory canal, can be per ormed with a ring block around
the base o the ear. Anesthesia to the concha and external auditory canal must be per ormed with local in ltration.

What is the treatment or ear burns?
T e primary goal is to prevent chondritis. opical ma enide is used or dressing changes. T e eschar is le t in place
as a biologic dressing. De ects with intact perichondrium will heal in, while others will require late excision and
repair.

What is the treatment or rostbite o the ear?
opical ma enide is used or burns and rostbite. It is highly soluble, which allows penetration o eschar and
cartilage. Sul onomides are carbonic anhydrase inhibitors, which can lead to metabolic acidosis.

What is the management o an ear hematoma?
Ear hematomas are treated by aspiration or incision and drainage. Bolster dressing is applied to prevent
reaccumulation. Hematoma orms between the cartilage and perichondrium o the ear. T is disrupts the vascular
supply to the cartilage, which may become necrotic or in ected. Clotted blood orms a brotic mass that de orms
the overlying tissue. T is is known as a “cauli ower,” “boxer’s,” or “wrestler’s” ear.

What are the most common malignancies o the ear?
1. Squamous cell cancer: 50% to 60%
2. Basal cell cancer: 30% to 40%
3. Melanoma: 1% to 2%

What are the causes o a prominent ear?
1. Underdeveloped antihelical old, leading to protrusion o the scapha and helical rim, causing prominence in
the upper to middle 1/3.
2. Prominent concha, causing middle 1/3 prominence.
3. Protruding earlobe, causing lower 1/3 prominence.

What is a constricted ear?
Abnormally small ears which may appear prominent due to the inadequate circum erence o the helical rim,
leading the auricle to cup orward.

746
Plastic & Reconstructive Surgery Board Review

What is a Stahl’s ear?
An ear with a third crus, in addition to the anterior and posterior crus o triangular ossa (Fig. 77-2).
Figure 77-2 Example o a Stahl’s ear. See Color insert.

What is cryptotia?
T e upper pole o the helix is buried beneath the temporal skin.

Auricular cartilage has notable plasticity in the immediate newborn period due to what?
Circulating maternal estrogens, which peak at day 3 and return to baseline at week 6.

What treatment may take place o or precede surgical intervention in newborns with ear de ormities such as
constricted ears?
Ear molding, which takes advantage o the early ear plasticity. Results are most success ul with earlier intervention,
ideally prior to 6 weeks o age.

What are the otoplasty goals?
From the ront view the helical rim should be visible and not hidden behind the antihelix, and rom the rear view
the helical rim should be straight, not “C” shaped.

How are de ects o skin and perichondrium repaired?
Primary closure is used or small de ects. T e cartilage may be removed and a skin gra t applied onto the medial
skin. Local skin aps such as bipedicled aps rom the medial ear may be used.

CHAPTER 77 Ear Reconstruction
747

What is the Antia–Buch reconstruction technique?
Antia–Buch technique o helical rim advancement can be used or de ects up to 2.5 cm. T e helical rim is
separated rom the scapha through an incision in the helical sulcus. T is extends rom the lower edge o the de ect
to the upper lobule, including skin, perichondrium, and cartilage. T e posteromedial skin is le t intact, whereas
the chondrocutaneous ap is advanced. V-Y advancement o the root helix and trimming scaphal cartilage allow
or additional coverage (see Fig. 77-3).
A

B
C

D
Figure 77-3 T e Antia–Buch reconstruction technique.

How are helical rim de ects greater than 3 cm treated?
T e Converse tunnel procedure is used or helical rim de ects greater than 3 cm. A cartilage strut is tunneled under
postauricular skin. T ree weeks later, the strut is li ted on an anteriorly based ap and inset into the de ect.

Describe the tubed pedicle technique.
T e tubed pedicle technique is used or helical reconstruction. A bipedicled ap is elevated and ashioned into a
tube. T is is sewn to the edge o the de ect. A second stage is per ormed to elevate the ap.

What are reconstructive options or the conchal bowl and helical root?
1. Healing by secondary intention.
2. Full-thickness skin gra ts can be placed onto perichondrium.
3. I the perichondrium is not present, the cartilage should be excised and skin gra t placed onto medial ear skin.

How large o a de ect can be closed primarily (i.e., Tanzer’s excision)?
A de ect o 2 cm or less can be closed using a wedge excision technique with star-shaped pattern to allow or
closure without excessive excision o the helical rim. T is is commonly re erred to as a anzer’s excision.

748
Plastic & Reconstructive Surgery Board Review

What is a Banner ap?
T is is a postauricular ap rom the superior auriculocephalic sulcus. It is used in conjunction with a cartilage gra t
or upper one-third de ects.

What are the reconstructive options or de ects o the middle one-third o the ear?
1. De ects limited to helical rim are closed by Antia–Buch technique.
2. Wedge excision with primary closure (i.e., anzer’s excision) (< 2 cm).
3. Cartilage gra t with postauricular or temporoparietal ap/skin gra t (i.e., Dief enbach’s ap or Converse tunnel
technique) (> 2 cm).
4. Contralateral chondrocutaneous composite ap (> 2 cm).

What is a Die enbach ap?
T is is a postauricular ap with contralateral cartilage support, which is used to reconstruct de ects o the middle
one-third. Cartilage gra t is sutured into the de ect with postauricular skin advanced over or skin coverage. T e
ap is then divided 2 to 3 weeks later (see Fig. 77-4).
A
C
B
D
Figure 77-4 Example o a Dief enbach ap.

CHAPTER 77 Ear Reconstruction
749

Is cartilage required or lobular reconstruction?
Although the lower ear is not composed o cartilage, reconstruction with cartilage provides better support. Wedge
excision and primary closure can be per ormed by de ects < 50%. Local preauricular and postauricular aps with
cartilage struts are used or de ects > 50%.

What is a split earlobe and how is this treated?
Split earlobe results rom a traumatic earring injury or heavy earring use. Straight line closure will result in a
notched earlobe. A wedge excision and zigzag repair can prevent notching.

Describe the use o the temporoparietal ascial ap in ear reconstruction.
T is super cial temporal ascia ap is based on the super cial temporal vessels. It is tunneled to the ear or
cartilage coverage and covered with skin gra t. It is a thin and pliable ap that preserves external topography. T is
is used when local skin aps are not available.

What is the management o partial ear amputation?
Partial amputation even with a wide small pedicle has good prognosis with debridement and primary closure.
Partial amputation with a narrow pedicle and a large amount o cartilage to support has a poor prognosis with
primary repair.

Describe the approach to total ear amputation.
Cartilage banking or the “pocket principle” is rarely used at this time due to cartilage degradation and de ormity.
Microvascular replantation should be attempted. I this is not possible, staged reconstruction should be per ormed.

What should be done i no suf cient venous out ow can be established or an ear replantation?
Leech therapy.

Do patients with microtia have hearing dif culties?
Most patients have atresia o the external auditory canal, tympanic membrane, and the middle ear ossicles
resulting in conductive hearing loss. T e inner ear is derived rom a separate embryologic tissue than the middle
and external ear.

At what age is ear reconstruction generally pursued?
T is is debated and may be as early as 5 years, or at age 9 to 10, when the opposite ear (and the ramework) or
modeling the reconstruction reaches adult size, and patients harbor enough rib cartilage to harvest.

What are the options or total ear reconstruction?
1. Autogenous reconstruction
2. Composite autogenous/alloplastic reconstruction with alloplastic ramework
3. Prosthetic

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Plastic & Reconstructive Surgery Board Review

Describe autogenous ear reconstruction.
Ear reconstruction involves multiple stages, number, order, and complexity depending on the technique. Brent’s
technique is a modi cation o anzer’s technique and involves our stages. It is simpler and with less risk o
complications. Nagata’s technique involves two stages and has the potential or a more optimal aesthetic result,
yet may be more challenging. A ramework is created using the contralateral ear as a model, and contralateral
or ipsilateral (depending on the technique) costal cartilages 6 to 8 or 5 to 9 or the structure. T is is placed in a
subcutaneous pocket. T e cartilage ramework is then li ted with the overlying skin and the posterior de ect is
covered with a skin gra t and rotated into anatomic position.

What determines the shape o the reconstructed ear?
T e cartilage ramework, but also the available options o tissue or coverage. T e ramework may need to be
adapted in consideration o any limitations o abnormal skin coverage.
REFERENCES
Allison GR. Anatomy o the external ear. Clin Plast Surg. 1978;5:419–422.
Antia NH, Buch VI. Chondrocutaneous advancement ap or the marginal de ect o the ear. Plast Reconstr Surg. 1967;39:472–477.
Bos EJ, Scholten , Song Y, et al. Developing a parametric ear model or auricular reconstruction: a new step towards patient-speci c
implants. J Craniomaxillofac Surg. 2015;43:390–395.
Boutros SG, T orne CH. Chapter 53. Reconstruction o acquired ear de ects. In: Guyron B, Erikkson E, Persing JA, eds. Plastic Surgery:
Indications and Practice. China: Elsevier; 2009:717–726.
Brent B. Reconstruction o traumatic ear de ormities. Clin Plast Surg. 1978;5:437–445.
Brent B. T e acquired auricular de ormity. A systematic approach to its analysis and reconstruction. Plast Reconstr Surg. 1977;59:
475–485.
Cheney ML, Hadlock A, Quatela VC. In: Baker SR, ed. Local Flaps in Facial Reconstruction. Philadelphia, PA: Elsevier; 2007:581–624.
Do t M, Goodkind A, Diamond S, DiPace J, Kacker A, LaBruna A. T e newborn butter y project: a shortened treatment protocol or
ear molding. Plast Reconstr Surg. 2015;135(3):577e–583e.
Elsahy NI. Acquired ear de ects. Clin Plast Surg. 2002;29:175–186.
Elsahy NI. Reconstruction o the ear a ter skin and cartilage loss. Clin Plast Surg. 2002;29:201–212.
Elsahy NI. Reconstruction o the ear a ter skin and perichondrium loss. Clin Plast Surg. 2002;29:187–200.
Firmin, F. State-o -the-art autogenous ear reconstruction in cases o microtia. In: Staudenmaier R. Aesthestics and Functionality in Ear
Reconstruction. Adv Otorhinolaryngol. Basel, Switzerland: Karger; 2010;25–52.
Gosain A, Kumar A, Huang G. Prominent ears in children younger than 4 years o age: what is the appropriate timing or otoplasty?
Plast Reconstr Surg. 2004;114(5):1042–1054.
Gosman AA, Reece EM. Ear reconstruction. In: Janis JE, ed. Essentials of Plastic Surgery. St Louis, MO: Quality Medical Publishing;
2007:314–323.
Lo J, sang W, Yu J, Ho O, Ku P, ong M. Contemporary hearing rehabilitation options in patients with aural atresia. Biomed Res Int.
2014;2014:761579.
Menick FJ. Reconstruction o the ear a ter tumor excision. Clin Plast Surg. 1990;17:405–415.
Songcharoen S, Smith RA, Jabaley ME. umors o the external ear and reconstruction o de ects. Clin Plast Surg. 1978;5:447–457.
T orne CH. Chapter 30. Otoplasty and ear reconstruction. In: T orne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL,
eds. Grabb & Smith’s Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:297–312.
urpin IM. Microsurgical replantation o the external ear. Clin Plast Surg. 1990;17:397–404.
Wilkes G, Wong J, Guil oyle R. Microtia reconstruction. Plast Reconstr Surg. 2014;134(3):464e–479e.

751
Farzad R. Nahai, MD

What makes up the anterior, middle, and posterior lamellae o the eyelid?
T e three lamellae or “layers” o the eyelid are anatomical divisions that help with the understanding o lid
unction and lid surgery.
T e anterior lamella is de ned as the skin and underlying orbicularis muscle.
T e middle lamella is the orbital septum and accompanying atty pads.
T e posterior lamella is the conjunctiva and levator apparatus and corresponding lower lid retractors.

Describe the sur ace anatomy ndings o the aged eyelid and the underlying structures responsible.
Four key eatures are apparent on the sur ace examination o the aged eyelid: contour irregularities, the lid crease,
lid position, and rhytids.
Contour irregularities that are o ten apparent are because o protruding periorbital at pads; principally the medial
upper at pad and the lower lid at pads.
An elevated lid crease represents stretch or dehiscence o the levator apparatus rom the tarsal plate and is o ten a
tell-tale sign o lid ptosis.
Lower lid position that is descended away rom the corneoscleral limbus is indicative o lower lid laxity and poor
canthal support. O ten a negative canthal tilt (downward slope o a line drawn rom the medial canthus to the
lateral canthus) and scleral show (a viewable strip o white sclera between the lower corneoscleral limbus and lid
border) are present as well. Upper lid position that encroaches on the upper corneoscleral limbus raises suspicion
that ptosis is present.
Brow strain and horizontal orehead rhytids o ten accompany lid ptosis and dermatochalasis.

What are the analogous structures in the upper and lower eyelid?
T e levator aponeurosis is speci c to the upper eyelid and is analogous to the capsulopalpebral ascia o the lower lid.

Describe the anatomy o the orbicularis oculi muscle.
T e orbicularis oculi muscle is a complex array o concentrically oriented muscles with origins medial to the
medial canthus and insertions lateral to the lateral canthus. Further di erentiation is made based on the location
relative to the underlying lid structures; oriented in a concentric manner rom outside to in they are the orbital
orbicularis, preseptal orbicularis, and pretarsal orbicularis. Further divisions (based on unction and innervation)
can be made, principally the inner canthal orbicularis and the extracanthal orbicularis.
Aesthetic and
Reconstructive Eyelid
Surgery
CHAPTER 78

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Plastic & Reconstructive Surgery Board Review

Describe the unctional role o the orbicularis muscle.
T e orbicularis muscle is responsible or eyelid closure (both passive blink and active squint), corneal protection,
and lubrication, and as a pump o the lacrimal sac. T e inner canthal orbicularis (that orbicularis which resides
within 1 cm o the medial canthus) is responsible or passive involuntary blink; the extracanthal orbicularis
(that orbicularis which resides outside the inner canthal portion) is responsible or voluntary protective orce ul
blinking.

Describe the location and unction o the lacrimal sac.
T e lacrimal sac resides lateral and posterior to the base o the nasal sidewall within the lacrimal crest. T e upper
portion o the sac is wrapped on its anterior and posterior aspects by the anterior and posterior medial heads o the
orbicularis muscle, hence the muscle’s pump action on it. T e lacrimal system is a conduit or the passage o tears
rom the eye (exiting via the upper and lower canalicular systems) into the nasal sinus. Obstruction within this
low-pressure system can result in epiphora (excess tearing) or mucocele.

What is Whitnall’s tubercle?
Whitnall’s tubercle is minor bony spur on the inner aspect o the lateral orbital rim that represents the bony
insertion point o the lateral canthal tendon.

What nearby anatomic structure helps locate Whitnall’s tubercle?
Eisler’s at pad is a minor at pad located super cial to and immediately above Whitnall’s tubercle immediately
under the orbital septum. Identi ying Eisler’s at pad is one method o locating the insertion o the lateral canthal
tendon.

What is Bell’s phenomenon?
T is is the re ex upward rotation o the globe during lid closure. T is acts as a urther protective mechanism o the
cornea. It is present in most patients but not in all.

How many atty compartments are there in the upper eyelid? Describe them. How can they be told apart?
T ere are two separate atty pads in the upper eyelid, the nasal or medial pad and the central pad. Both reside
directly under the orbital septum and super cial to the levator apparatus. T e medial atty pad is located above
the medial canthus and can be identi ed by its whitish-yellow color. T e central atty pad is more centrally located
approximating the level o the medial corneoscleral limbus and is deeper yellow in color.

How many atty compartments are there in the lower eyelid? How can they be told apart?
In contrast to the upper eyelid, the lower eyelid has three atty compartments; the nasal (or medial), central, and
lateral atty pads. Similarly, the medial atty pad is more whitish-yellow in color and the other two are deeper
yellow.

What structure divides the medial rom the central atty pad in the lower eyelid?
T e in erior oblique muscle divides the medial rom the central atty pad in the lower eyelid. It is because o this
location that it is at high risk or injury during lower lid procedures. Extreme caution should be exercised when
manipulating the central or medial atty pads to avoid injury to this extraocular muscle.

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What is the most commonly injured muscle in upper lid blepharoplasty?
T e superior oblique. It resides deep and medial to the medial at pad.

Describe the innervation o the orbicularis muscle.
T e di ering unction o the orbicularis is based on its anatomic location and is re ected in its di ering nerve
input.
T e extracanthal orbicularis muscle is primarily responsible or purpose ul, voluntary, and orce ul lid closure. T is
portion o the muscle is innervated by branches o the rontal and zygomatic branches o the acial nerve.
T e inner canthal orbicularis (that portion o the muscle in proximity to the medial canthus) is responsible or
involuntary lid closure and blinking. T is muscle is primarily driven by buccal branch innervation. Injury to
the buccal branch or inner canthal orbicularis can severely a ect proper lid unction and corneal lubrication and
protection. T e extracanthal orbicularis is more expendable.

What is the di erence between blepharochalasis and dermatochalasis?
Blepharochalasis is characterized by intermittent in ammation o the eyelid with exacerbations and remissions
o eyelid edema. T is process results in a stretching and subsequent atrophy o the eyelid tissue and over time
recurrent episodes and aged appearance. T ere is typically no associated pain or erythema and it primarily a ects
young women. Dermatochalasis is de ned as an excess o skin o the eyelids that is congenital or age related.

What are three common presenting ndings in upper lid ptosis?
Depressed lid position, brow strain, and a high-riding or absent lid crease.

What are the degrees o levator unction?
Levator unction is expressed as the distance between excursion o upper lid margin rom ull down gaze to ull up
gaze without brow movement. Excellent (> 10 mm), good (8–10 mm), air (5–7 mm), or poor (1–4 mm). T e
proper procedure or ptosis repair is o ten based on levator unction.

What are the common methods o ptosis repair?
Fasanella–Servat procedure is an example o a transconjunctival approach to ptosis repair. Levator advancement is
an example o open transcutaneous ptosis repair. Lid suspension to the brow with either ascia or a silicone sling is
an example o a procedure used or severe ptosis with minimal levator unction.

What are the di erences between the Asian eyelid and the Occidental eyelid?
Asian eyelids are marked by the presence o epicanthal olds and lack o pretarsal show. T e lid crease is
signi cantly lower relative to the ciliary margin than that o Caucasian eyelids (4–6 mm compared with
8–10 mm). T e insertion o the orbital septum relative to the tarsus is lower in Asian eyelids, thus periorbital at is
typically seen lower in the eyelid and closer to the lid crease compared with Caucasians. T e Asian lid crease may
or may not obscure the medial canthus.

What are the goals o Asian eyelid surgery?
T e “double eyelid surgery” ocuses on establishing a modicum o visible pretarsal lid and developing a lid old
that is seen separately rom the lid margin, preserving the epicanthal old. Incisions are made within the lid at the
desired level o old creation, excess at is removed, and xation sutures are placed to control the height o the lid
crease. It is critical to maintain a low lid crease and the epicanthal old, lest a Caucasian eyelid result occurs.

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Plastic & Reconstructive Surgery Board Review

What are the surgical options or minimal upper lid ptosis repair with good levator unction?
For minimal ptosis, Müeller muscle conjunctival resection or the Fasanella–Servat procedure is proposed.

What are the options or moderate ptosis with air levator unction?
Shortening o the levator palpebrae or levator muscle advancement is proposed.

What is the treatment or severe ptosis with poor levator unction?
For severe ptosis with a levator unction < 5 mm, a brow/ rontalis suspension is indicated.
RECONSTRUCTION

What are the undamental dictums o eyelid reconstruction?
Reconstruction o any lid de ect must take into account lining, support, and coverage. Lining re ers to the
conjunctiva that will protect the cornea, support re ers to the rigid tarsus and medial and lateral canthal tendons,
and coverage is the skin and muscle that cover everything. Basically, the three lamellar layers o the eyelid are
considered and each one must be accounted or in the reconstruction.

How are lid de ects o less than 25% o the total lid width repaired?
In general, upper and lower eyelid de ects that are less than 25% the total width o the lid can be repaired by
primary closure. It is important that portion o the de ect that contains the tarsal plate be made at a right angle
relative to the ciliary margin. T is will acilitate a closure that minimizes any contour irregularity or notching
along the lid margin. T e remaining portion o the de ect outside the tarsus is managed based on the presentation.
In cases with poor lower lid laxity, consideration must be given to a concomitant lid support procedure such as a
canthopexy or canthoplasty.

How are lid de ects between 25% and 50% o the total lid width repaired?
Lid de ects between 25% and 50% the total length o the lid must incorporate the import or rotation o new
tissue or reconstruction. Primary lid closure is not easible in these situations. An assessment must be made as to
whether the de ect is “shallow and wide” or “deep and narrow.” Shallow and wide de ects o the lower eyelid can
o ten be repaired by recruitment o lower eyelid and mid ace tissue, similar to vertical vector aesthetic lower lid
procedures. Deep and narrow de ects o the lower eyelid will require rotation and advancement o laterally based
tissue. For the lower eyelid, a enzel ap, a laterally based rotation advancement ap, is commonly used. Lateral
canthal support must be per ormed as well. A common ap or the upper eyelid is the ripier ap, an axially based
upper eyelid myocutaneous ap.

How are lid de ects that are greater than 50% o total lid length repaired?
Shallow and wide de ects o the lower eyelid may still be reconstructed with mid ace advancement although a
cartilage gra t is o ten needed to reconstruct the tarsal plate. Lateral canthal support must also be per ormed with
intact tissue or imported tissue in the orm o the gra t or local tissue such as a turn over temporal ascial ap
or turn over lateral orbital wall periosteal ap. otal eyelid reconstruction requires a “lid-sharing” technique; a
Hewes ap ( rom the upper lid) to reconstruct the lower eyelid or a Cutler-Beard ap ( rom the lower eyelid) to
reconstruct the upper eyelid.

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What is a Hewes f ap? What is a Hughes f ap?
T ese are both conjunctival lid-sharing aps rom the upper eyelid that include a portion o the tarsal plate. T ese
aps are best or wide and deep lower lid de ects, typically greater than 5 mm in height. T e Hewes ap preserves
an attachment to the lateral canthal tendon when needed or lower lid reconstruction (best or de ects that include
the lateral aspect o the lower lid); the Hughes ap does not, it is purely the tarsus and the conjunctiva, no canthal
tendon. (A help ul way to di erentiate the two, Hewes with an “e” like tendon with an “e.”) T ese aps are
maintained on their upper lid pedicle or 4 to 6 weeks be ore separation and inset. Both o these aps will require
some sort o coverage by either a rotational ap or a skin gra t.

What is a Cutler-Beard f ap?
T is is a ull-thickness ap o skin, muscle, conjunctiva, and/or cartilage rom the lower lid used to reconstruct
large ull-thickness upper lid de ects. T is lid-sharing ap is maintained on its lower lid pedicle or 4 to 6 weeks
be ore separation and inset.

What is a Mustardé f ap?
T is is medially based acial ap utilized or very large lower lid and malar de ects that cannot be reconstructed
with the above-listed techniques. A Mustardé ap is a large rotation advancement ap made up o the entire cheek
and lower ace. T e releasing incision is made over the zygomatic arch, continues caudally in ront o the ear, and
extends down into the neck where the back cut is made.
UPPER LID COSMETIC

What is an “A- rame” de ormity?
T e A- rame de ormity can be the result o aging or aggressive periorbital at removal in the upper eyelid. T e
youth ul upper eyelid has a smooth arched contour. T e A- rame de ormity is a peak-shaped depression o the
medial portion o the upper eyelid similar to an A- rame, or two segments meeting at a right angle, thus disrupting
the smooth arch. Hollowing o the upper eyelid rom age-related at atrophy or overresection o the medial aspect
o the central at pad can lead to an A- rame de ormity.

Describe the anatomic eatures that make up the upper lid crease.
T e upper lid crease is a result o the dermal insertion o the tarso-levator muscle as it terminates and inserts onto
the tarsal plate. Fibers extend rom the upper aspect o the tarsal plate, penetrate the pretarsal orbicularis, and
terminate on the dermis o the eyelid skin. T e location o these bers extending into the dermis determines the
location o the lid crease.

How are the central and medial atty pads o the upper lid identi ed?
T e central and medial atty pads o the upper eyelid reside deep to the orbital septum. Interpad septae separate
the two and they di er in color, the medial atty pad is a pale whitish-yellow and the central at pad is straw yellow
in color.

What is the open sky technique in upper lid blepharoplasty?
T is describes a method o upper lid blepharoplasty that removes excess skin, muscle, and orbital septum en bloc.

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Describe the general principles behind upper lid markings or blepharoplasty.
In general, markings are made to preserve the upper lid crease and levator attachments to the dermis, preserve
adequate skin or eyelid closure, and maintain a smooth old arch. T e actual amount o skin and muscle removed
rom each lid may di er based on patient presentation so it is important to remember that markings are o ten
based on what skin is le t behind rather than what skin is removed. In general, the skin resected medially is done
more conservatively while one can remove more skin laterally.

Can an upper lid blepharoplasty and a ptosis repair be done at the same time?
Yes, this is considered a transcutaneous ptosis repair. A ter the removal o the excess skin and muscle, the tarsal
plate and levator muscle can be readily exposed and repaired by tarso-levator advancement.

What is lagophthalmos and how is it avoided during blepharoplasty?
Lagophthalmos is an inability to close the eyelid ully. T is increases the risk o corneal exposure and damage.
T ere are three main causes associated with eyelid surgery:
1. excessive upper lid skin removal
2. injury to the buccal branch o the acial nerve that innervates the inner canthal orbicularis muscle responsible
or blinking
3. poor lateral canthal support resulting in sh mouth eyelid closure
T ese complications are avoided by:
1. care ul measurement o upper eyelid markings prior to resection and preserving a critical amount o upper lid skin
2. avoiding dissection within the so t tissues o the lower lid medial to the level o the medial corneoscleral limbus
3. per orming canthoplasty/pexy and proper lateral canthal support in open lower lid procedures

Can a protruding upper medial atty pad be treated without incising the lid skin?
Yes, by per orming a transconjunctival upper lid blepharoplasty. T is technique accesses the upper medial at pad
through an upper lid conjunctival incision above and medial to the medial horn o the tarsal plate. T is procedure
is indicated in the patient without upper lid skin excess but a bulging medial at pad alone.
LOWER LID COSMETIC

What type o patient will get the best result rom a transconjunctival lower lid blepharoplasty?
ransconjunctival lower lid blepharoplasty addresses excess periorbital at by means o at resection and/or
at redraping. T e best candidates to have only their at addressed are typically younger patients who have at
protrusion with normal skin tone and minimal wrinkles, and normal lid tone and lid position. In addition, a
transconjunctival approach can be combined with a skin pinch on the sur ace or skin resur acing by means o
chemical peel or laser.

What layers in what order are transected during a transconjunctival lower lid blepharoplasty in order to
reach the orbital at?
Beginning rom the conjunctiva the layers are as ollows: lid conjunctiva, capsulopalpebral ascia, and orbital
septum. T e preseptal approach is pre erred as more precise at resection can be per ormed and the at does not
obstruct the view and access to orbital rim. In the direct approach, the capsulopalpebral ascia and septum are
bypassed and the lower lid retractors are divided to directly access the periorbital at.

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What are the bene ts o the lower lid transconjunctival approach?
No visible external scar, quick recovery, less risk or complications such as lower lid malposition (Fig. 78-1).
Figure 78-1 Reproduced with permission rom Nahai F. T e Art o Aesthetic Surgery: Principles & echniques. St Louis, MO: Quality Medical
Publishing, Inc.; 2005:729.

What are the limits o the lower lid transconjunctival approach?
Only e ective at at removal or repositioning. Can be a challenging dissection. Will not treat the skin. Access to
the lateral at pad can be dif cult.

What are the ndings that indicate a lower lid blepharoplasty patient who is at high risk or postoperative
lid malposition?
Lower lid laxity (displacement o the lid more than 10 mm rom the globe), poor snap test, exophthalmos, prior
lid surgery, scleral show, Grave’s disease, negative vector mid ace. I these ndings are present, canthal anchoring is
considered mandatory during lower lid blepharoplasty.

What are some o the non-surgical options or lower lid rejuvenation?
Fine crepe like lines, that in general do not respond well to surgery can be improved signi cantly with chemical
peels or laser resur acing. Lower lid atty pad prominence and a deep periorbital groove can be treated with
hyaluronic acid gel llers. T e younger the patient and the less overall signs o ageing around the eyelid, the more
e ective the nonsurgical options are.

What is a skin-muscle f ap and how is it developed during a lower lid procedure?
T e skin-muscle ap re ers to the ap o lower eyelid skin and underlying orbicularis muscle that is elevated to
access the orbital septum and orbital at. T e easiest method to dissect and develop the skin muscle ap is through
a subciliary lid incision preserving pretarsal orbicularis and staying within the preseptal plane. T is dissection can
be brought to the level o the orbital septum and urther into the mid ace i indicated. A portion o the skin and
muscle is typically resected during lower lid blepharoplasty to achieve an aesthetic result.

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What is the orbitomalar ligament and what is achieved by releasing it?
T e orbitomalar ligament is a dense extension o bers rom the periosteum o the orbital rim that extends to
and through the orbicularis muscle and terminates in the dermis o the overlying lid skin. It is the landmark
demarcation between the lower lid and the mid ace. Releasing the orbitomalar ligament enhances lower lid skin
and muscle mobility in a cephalad vector, blunts the lid cheek junction, acilitates reduction o malar estoons,
accommodates at redraping, and provides a gateway to the mid ace.

What is the di erence between a canthoplasty and a canthopexy?
Both o these are suture techniques employed to strengthen the lateral canthus and support the lower eyelid, both
terms are also re erred to as canthal anchors. A canthopexy is a tightening lateral canthal anchoring procedure that
corrects laxity o the lateral canthal tendon without tendon release or partial resection. A canthoplasty is a more
aggressive means o lateral canthal anchoring that involves division o the lateral canthal tendon and/or lower lid
margin shortening by wedge resection with permanent repositioning.

Where is the correct placement or a canthopexy/plasty suture?
A lateral canthal anchor suture used in canthoplasty or canthopexy should result in proper lid position, lid tension,
and lid shape. Most o ten the suture should be placed several millimeters deep to the sur ace o the orbital rim on
the inner aspect o the lateral orbital wall within the periosteum at the mid-pupillary line (this approximates the
location o Whitnall’s tubercle). Slight alterations to this position are made or enopthalmos and exophthalmos.
T e bite on the lid margin is within the posterior lamella where the tarsal plate and canthal tendon reside.

How is “ at redistribution” per ormed and what are its bene ts?
When transposition o eyelid at is indicated, periorbital at must be released rom the overlying orbital septum
and interpad septa. During dissection it is important to keep the pedicle to the at intact. T e at is then
positioned into the desired location (i.e., over the orbital rim or into the tear trough) and secured based on the
surgeon’s pre erence. Options or securing the at included suturing to the periosteum, suturing to the local ascia
or muscle, or transcutaneous sutures that are clipped later.

When at resection is per ormed, how does the surgeon know when to stop?
Fat resection in the lower eyelid is indicated i there is a signi cant excess o at and there is no plan to transpose
the at over the rim. In these cases, medial, central, and lower eyelid at should be treated so that a smooth contour
is achieved in the nal result. A sa e point at which at resection is adequate enough to achieve a desirable result is
to contour the at level with the in erior orbital rim. Excessive at removal can lead to orbital hollowing.

How are retrobulbar hematomas diagnosed?
Retrobulbar hematoma is a rare complication o blepharoplasty caused by bleeding deep to the orbital septum
that occurs within the rigid enclosure o the bony orbit. A small amount o blood in a small rigid space can cause
symptoms and severe damage rapidly. Patients with retrobulbar hematomas typically complain o rapid onset,
worsening, severe, and lancinating pain in the globe and orbit. T is is o ten associated with severe proptosis and
diminished visual acuity. As compression on the central retinal artery and optic nerve progresses, temporary or
permanent blindness can occur. Such complaints are assumed to be and treated as a retrobulbar hematoma until
proven otherwise.

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How are retrobulbar hematomas treated?
Ideally a retrobulbar hematoma is diagnosed early and treated as an emergency. Patients with retrobulbar
hematomas typically complain o rapid onset, worsening, severe, lancinating pain in the globe and orbit. Any
complaints in the postoperative time period o increasing pain, proptosis, and loss o vision should be considered
and treated as a retrobulbar hematoma until proven otherwise.
reatment involves immediate release o the sutures, canthotomy, operative exploration, evacuation o blood,
proper hemostasis, control o hypertension, and intravenous corticosteroids and acetazolamide to decrease
swelling. Strongly consider ophthalmologic consultation to assess vision and the globe. Once the situation is under
control, the canthus and sur ace incisions can be closed.

What are the potential causes o diplopia or blurry vision a ter eyelid surgery?
T ere are many potential causes o double vision or blurry vision a ter eyelid surgery: periorbital swelling, dry eyes,
ophthalmic ointments, permanent or temporary injury o the extraocular muscles (principally the superior oblique
or in erior oblique muscles), corneal exposure, corneal abrasion, and in ection. Persistent diplopia or blurry vision
(lasting more than 3–4 weeks) deserves a ormal workup and consultation with an ophthalmologist.

What is chemosis and how is it treated?
Chemosis is an in ammatory edematous phenomenon that occurs within the scleral portion o the conjunctiva
o the globe. Akin to a blister, chemosis is believed to be the result o local trauma, exposure, and temporary
lymphatic drainage obstruction secondary to eyelid surgery. reatment options include topical steroid
containing drops or ointments, lubricating compounds, tarsorrhaphy sutures, patching and compression, and
conjunctivectomy.

How is lower lid malposition or ectropion acutely treated?
Mainly taping and massage, tarsorrhaphy sutures in severe cases with exposure and lack o Bell’s phenomenon.
Application o obliquely oriented strips o tape can o er some support to the lateral canthus and oppose the
cicatricial orce causing the ectropion. Massage helps reduce swelling that a ects lid position and unction. More
advanced management options include injections o dilute triamcinolone and 5- urouracil to control and slow
down the internal scar process, and injections o hyaluronic acid gels llers to create an internal support structure
or the lower lid.

How is persistent lid malposition or ectropion treated?
T is is variable based on the degree o malposition. Options range rom canthopexy/plasty alone, canthopexy/
plasty and spacer gra t, or canthopexy/plasty and spacer gra t and mid ace recruitment. In the severe or recurrent
cases, a ascial sling, skin gra t, or local aps may be needed. T e Patipa nger displacement test can be used to
help decide which procedures may be necessary.
REFERENCES
Codner MA, Wol i JN, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support. a comprehensive
10-year review. Plast Reconstr Surg. 2008;121(1):241–250.
Di rancesco LM, Codner MA, McCord CD. Upper eyelid reconstruction. Plast Reconstr Surg. 2004;114(7):98e–107e.
Eser Y, Potochy J, Spira M, Shenaq SM. A Dif erential Approach to the Mid ace Li t: An Anatomic and Clinical Study. Seattle, WA: 81st
Annual Meeting o the American Association o Plastic Surgeons; 2002.
Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27:193–204.

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Plastic & Reconstructive Surgery Board Review
Glatt HJ. ransconjunctival ap supplementation: an approach to the reconstruction o large lower eyelid de ects. Ophthal Plast Reconstr
Surg. 1997;13:90–97.
Jacobs S. Prophylactic lateral canthopexy in lower blepharoplasties. Arch Facial Plast Surg. 2003;5:267–271.
Jelks G, Jelks E. Blepharoplasty. In: Peck GC, ed. Complications and Problems in Plastic Surgery. 5th ed. New York, NY: Gower Medical
Publishing; 1992:18–19.
Lelli GR, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg. 2010;125(3):1007–1017.
McCord C, Nahai FR, Codner MA, Nahai F, Hester R. Use o porcine acellular dermal matrix (Enduragen) gra ts in eyelids: a review
o 69 patients and 129 eyelids. Plast Reconstr Surg. 2008;122(4):1206–1213.
McCord CD Jr, Ellis DS. T e correction o lower lid malposition ollowing lower lid blepharoplasty. Plast Reconstr Surg. 1993;92(6):
1068–1072.
Pacella SJ, Nahai FR, Nahai F. ransconjunctival blepharoplasty or upper and lower eyelids. Plast Reconstr Surg. 2010;125(1):384–392.
Patipa M. ransblepharoplasty lower eyelid and mid ace rejuvenation: part I. Avoiding complications by utilizing lessons learned rom
the treatment o complications. Plast Reconstr Surg. 2004;113(5):1459–1468.
Patipa M. ransblepharoplasty lower eyelid and mid ace rejuvenation: part II. Functional applications o mid ace elevation. Plast
Reconstr Surg. 2004;113(5):1469–1474.
Shin YH, Hwang K. Cosmetic lateral canthoplasty. Aesthetic Plast Surg. 2004;28:317–320.
yers AG, Collin JRO. Levator aponeurotic repair. In: Colour Atlas o Ophthalmic Plastic Surgery. Ox ord: Butterworth-Heinemann,
1998:130–139.
Wein eld AB, Burke R, Codner MA. T e comprehensive management o chemosis ollowing cosmetic lower blepharoplasty. Plast
Reconstr Surg. 2008;122(2):579–586.

761
Brian M. Parrett, MD and
Julian J. Pribaz, MD

What are the aesthetic subunits o the nose and what is the subunit principle?
T e alae, the columella, the so t triangles, the tip, the sidewalls, and the dorsum. T e basic tenet o the subunit
theory explains that i a de ect encompasses more than 50% o a given subunit, a better aesthetic result will be
achieved by complete excision and replacement o the subunit with suitable tissue.

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, whereas the skin o the tip and alae is denser
and more sebaceous.

What are the three principles that guide reconstruction o any ull-thickness nasal de ect?
A satis actory reconstruction must provide nasal lining, structural ramework (cartilage or bone), and
aesthetically appropriate skin coverage.

What are the potential donor sites or ull-thickness skin gra ting o nasal de ects and why are skin gra ts not
the best treatment option or most nasal de ects?
Preauricular, postauricular, and supraclavicular skin provide the best color and quality match or nasal skin. Skin
gra ts can result in color and contour de ormities and the possibility o secondary contracture in the nose.

What nasal regions have the best and worst aesthetic results when allowed to heal by secondary intention?
T e best results with secondary intention are on the medial canthal area and glabella. T e worst results are on the
nasal tip.

What are common donor sites or reconstructing the cartilaginous and bony ramework o the nose?
T e nasal septum, auricular conchal cartilage, and rib cartilage provide cartilage gra ts. For bone gra ts, split cranial
( rom the parietal skull), rib or iliac crest may be used.
Nasal Reconstruction
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Plastic & Reconstructive Surgery Board Review

What are the best methods to prevent cartilage warping?
Perichondrium should be removed rom nasal cartilage gra ts to prevent warping or curling. o prevent warping,
the cartilage gra t should be designed symmetrically and allowed to sit at least 30 minutes prior to insertion.

What is the blood supply to the dorsal nasal f ap and what nasal regions can it reconstruct best?
T e angular artery (terminal segment o the acial artery) provides blood supply to this ap. T e dorsal nasal ap is
best used or midline dorsal de ects less than 2.0 cm.

What are the two most versatile local f aps or reconstruction o the ala?
T e bilobed ap is best used or de ects less than or equal to 1.5 cm in diameter and the nasolabial ap is best used
or de ects > 1.5 to 3 cm in diameter. In addition, central tip and medial de ects are more likely treated with a
bilobed ap and lateral alar de ects are more likely treated with a staged nasolabial ap.

What are the two best options or reconstruction o a ull-thickness alar rim de ect?
A composite gra t rom the ear or de ects less than 1.5 cm and a staged nasolabial ap or de ects greater than 1.5 cm.

What are key steps in the use o composite gra ts?
T e gra t recipient site should ideally be allowed to heal by secondary intention prior to gra t placement. T e
de ect is then recreated with the goal to maximize gra t contact with vascularized tissue, that is, turnover o scar
tissue. T e gra t should be designed so that no portion is greater than 1 cm rom a vascularized recipient site
wound edge. Postoperative cooling with iced saline compresses over the gra t can improve survival.

How do you best design a bilobed f ap and what is the total rotation?
A proper design, known as the Zitelli modi cation, should limit the total rotation about the pivot point to 90 to
100 degrees (45–50 degrees per lobe), with the smaller second ap placed in the loose skin o the nasal dorsum or
sidewall (Fig. 79-1).
90 –100°
First lobe = Defect size
Tip trimmed from
second flap
Each flap rotates
45–50° only
= Defect radius
Pivot point
Figure 79-1 Zitelli’s design or the bilobed ap. A triangular excision is needed between the pivot point and the de ect to avoid dog-ear
ormation. Diameter o rst lobe is equal to that o the de ect; the second lobe is made smaller. Wide undermining just above the periosteum
is needed keeping the nasal muscles within the aps; avoid subcutaneous dissection.

CHAPTER 79 Nasal Reconstruction
763

What is the blood supply o the nasolabial f ap?
ributaries o the acial artery and its angular branch, which per orate the levator labii muscle near the ala and
radiate across the cheek. T e ap can be in eriorly or superiorly (more common) based and o ten requires two
stages (division 3 weeks later).

What is the ideal donor tissue or larger de ects o the nasal tip and alae?
A orehead ap is best used or de ects > 3 cm, especially when multiple subunits are involved.

What is the blood supply o the orehead f ap and when should the second stage (division and inset) be
per ormed?
T e supraorbital and supratrochlear arteries provide blood supply; the commonly used paramedian orehead ap
is supplied by the supratrochlear vessels primarily. T e supratrochlear vessels exit the orbit over the periosteum,
pass through corrugator muscles and, 2 cm above the supraorbital rim, pierce the rontalis muscle and then run
vertically in subcutaneous at close to the dermis. T e second stage ( ap division) should be per ormed 3 to
4 weeks a ter the rst stage.

What are the stages o , and the advantages o , the three-stage orehead f ap?
Many surgeons are now using the three-stage orehead ap. T e rst stage is orehead ap elevation and inset with
minimal to no ap thinning. T e second stage 3 to 4 weeks later involves re-elevating the distal ap, thinning it
considerably, and shaping the underlying ramework with addition o cartilage gra ts i needed. T e third stage is
division o the pedicle and ap inset 3 to 4 weeks a ter the second stage. T is is use ul in smokers or in major (near
total) nasal reconstructions as no ap thinning in the rst stage avoids ap necrosis and contour irregularities. In
ull-thickness de ects, it allows skin gra t placement or a olded ap or lining reconstruction in the rst stage and
then cartilage gra t placement in the second stage.

What is the approach or an adequately sized orehead f ap that leaves too large a orehead de ect or
primary closure?
T e donor site de ect can be easily treated with healing by secondary intention with dressing changes. Do not
place a skin gra t as it leads to poor aesthetic results.

When must ramework be supplied?
Anytime the inherent cartilaginous architecture o the nose is compromised.

T e alar wings do not normally contain cartilage; why must they be supported by cartilage when
reconstructed?
o resist the centripetal contractile orces o a healing tissue ap and subsequent alar notching and retraction.

What are the principles guiding selection o adequate nasal lining?
Adequate vascular supply, suf cient pliability to con orm to a concave contour, and appropriate thinness to avoid
airway obstruction.

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Plastic & Reconstructive Surgery Board Review

What are options or nasal lining?
Redundant skin olded over rom the coverage ap, skin gra t on the undersur ace o a ap, mucoperichondrial
aps rom the septum, rotational or advancement aps rom residual vestibular lining, acial artery
musculomucosal aps, or ree aps or larger de ects.

What is the blood supply to the septal mucoperichondrial f aps?
When based in eriorly, a septal branch o the superior labial artery that enters the nasal septum lateral to the nasal
spine provides blood supply. T e hinge ap design is based on the dorsum o the septum and supplied via the
anterior ethmoidal vessels.

What is the role o ree microvascular tissue trans er in nasal reconstruction?
Free aps (mainly the radial orearm) are used or total or subtotal, multilayered nasal reconstruction. In this
scenario, ree aps are used or nasal lining in the rst stage. Although quite bulky, the robust vascular supply o
the ree ap results in negligible contraction o the tissue, which is care ully thinned in subsequent procedures
and then covered with cartilage gra ts and a orehead ap or skin coverage. Burget and Walton have detailed their
work in the dif cult area o subtotal or total nasal reconstruction.
REFERENCES
Burget GC, Menick FJ. T e subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239–247.
Burget GC, Walton RL. Optimal use o microvascular ree aps, cartilage gra ts, and a paramedian orehead ap or aesthetic
reconstruction o the nose and adjacent acial units. Plast Reconstr Surg. 2007;120:1171–1207.
Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010;125:138e–150e.
Parrett BM, Pribaz JJ. An algorithm or treatment o nasal de ects. Clin Plast Surg. 2009;36:407–420.
Zitelli JA. T e bilobed ap or nasal reconstruction. Arch Dermatol. 1989;125:957–959.

765
Melissa M. Poh, MD and
Matthew M. Hanasono, MD
GENERAL

What is the anatomy o the mandible?
T e mandible consists o two bony halves used in the midline (symphysis). Each hemimandible consists o a
condyle, neck, ramus, angle, and body. T e masseter, temporalis, and medial pterygoid muscles close the mouth.
T e lateral pterygoid muscle protracts the mandible and opens the mouth. T e digastric, mylohyoid, geniohyoid,
and genioglossus muscles also help open the mouth.

What is the blood supply to the mandible?
T e in erior alveolar artery, which is a terminal branch o the maxillary artery. It courses within the mandible along
with the in erior alveolar nerve. T e mandibular periosteum also provides additional blood supply.

What nerve supplies sensation to the mandible?
T e in erior alveolar nerve, which enters the mandible on the lingual side o the ramus through the mandibular
oramen. It travels through the mandible supplying sensation to the teeth, then a branch (mental nerve) exits the
mandible at the mental oramen to supply sensation to the lower lip. Lower lip cancers can invade the mandible
by perineural spread along the mental and in erior alveolar nerves, in addition to involving the mandible by direct
extension.

What is the unction o the mandible?
T e mandible is essential or normal mastication, swallowing, and speech. It also sets the proportions and aesthetic
contours o the lower ace.

What are the goals o mandibular reconstruction?
1. Reestablish acial balance and symmetry.
2. Create a sur ace or mastication or dental restoration.
3. Prevent deviation o jaw leading to malocclusion.
4. Provide a stable wound that does not result in orocutaneous stula.
Mandibular
Reconstruction
CHAPTER 80