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&
AESTHETIC
R ECONSTRUCTIVE
PLASTIC SURGERY

(Trang không có chữ)

E D I T O R
JAMES C. GROTTING, MD
Clinical Professor, Division of Plastic Surgery,
University of Alabama at Birmingham;
Private Practice, Grotting Plastic Surgery,
Birmingham, Alabama
ILLUSTRATED BY
Jennifer N. Gentry, MA, CMI
2007
&
AESTHETIC
R ECONSTRUCTIVE
PLASTIC SURGERY
SECOND EDITION

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Ali Al-Attar, MD, PhD
Resident, Department of Plastic Surgery, Georgetown
University Hospital,Washington, DC
Al S. Aly, MD
Private Practice, Iowa City Plastic Surgery, Coralville,
Iowa
Adel Hussein Amr, MB, BCh, MSc
Assistant Lecturer in Plastic and Reconstructive Surgery,
Department of Plastic and Reconstructive Surgery,
Ain Shams University, Cairo, Egypt
Carl C. Askren, MD
Assistant Clinical Professor, Department of Surgery,
Plastic Surgery Section, University of California–
San Francisco/ Fresno, Fresno, California
Alexander W. Baker, BA
Research Assistant, Department of Psychiatry, Center
for Weight and Eating Disorders, University of Pennsyl-
vania School of Medicine, Philadelphia, Pennsylvania
Tracy M. Baker, MD
Instructor in Surgery, Department of Surgery, Division
of Plastic Surgery, University of Miami; Attending
Surgeon, Baker Plastic Surgery, Miami, Florida
Ricardo Baroudi, MD
São Paulo, Brazil
Bruce S. Bauer, MD, FAAP
Chief, Division of Plastic Surgery, Children’s Memorial
Hospital; Professor of Surgery, Division of Plastic
Surgery, Feinberg School of Medicine, Northwestern
University, Chicago, Illinois
v
Elisabeth K. Beahm, MD
Associate Professor, Department of Plastic Surgery,
The University of Texas M.D. Anderson Cancer Center,
Houston,Texas
John Bostwick III, MD†
Former Professor and Chairman, Division of Plastic,
Reconstructive, and Maxillofacial Surgery, Emory
University School of Medicine, Atlanta, Georgia
Dean E. Burget, Jr., MD
Staff Surgeon/ Private Practice, Department of Plastic
Surgery, Jennersville Regional Hospital,West Grove,
Pennsylvania
Gary C. Burget, MD
Associate Clinical Professor, Section of Plastic and
Reconstructive Surgery, University of Chicago, Chicago,
Illinois
Joseph F. Capella, MD
Department of Plastic Surgery, Hackensack University
Medical Center, Hackensack; Private Practice, Capella
Plastic Surgery, Ramsey, New Jersey
Grant W. Carlson, MD
Wadley R. Glenn Professor of Surgery, Department of
Surgery, Emory University, Atlanta, Georgia
James H. Carraway, MD
Professor and Chairman, Division of Plastic Surgery,
Eastern Virginia Medical School, Norfolk,Virginia
Kristoffer Ning Chang, MD
Associate Clinical Professor of Surgery, Department
of Surgery, University of California–San Francisco,
San Francisco, California
†Deceased.
C on t r i but or s

vi
Contributors
Simon H. Chin, MD
Former Chief Resident, Section of Plastic Surgery,Yale
School of Medicine, New Haven, Connecticut; Hand
Fellow, Department of Orthopaedics, University
of Washington, Seattle,Washington
Mark A. Codner, MD
Clinical Assistant Professor, Department of Plastic and
Reconstructive Surgery, Emory University; Paces Plastic
Surgery, Atlanta, Georgia
Alvin B. Cohn, MD
Aesthetic and Breast Fellow, Grotting Plastic Surgery,
Birmingham, Alabama
Sydney R. Coleman, MD
Department of Plastic and Reconstructive Surgery,
New York University School of Medicine, New York,
New York
Grady B. Core, MD
President, Core and Associates, Birmingham, Alabama
Paulo da Paula, MD
Former Visiting Fellow, Division of Plastic and Recon-
structive Surgery,The Milton S. Hershey Medical Center,
Pennsylvania State University, Hershey, Pennsylvania
Jorge I. de la Torre, MD
Associate Professor and Residency Director, Division of
Plastic Surgery, University of Alabama at Birmingham,
Birmingham, Alabama
A. Lee Dellon, MD
Director, Dellon Institutes for Peripheral Nerve Surgery,
Baltimore, Maryland
Stamatia V. Destounis, MD
Clinical Associate Professor, Department of Radiology,
University of Rochester; Radiologist, Elizabeth Wende
Breast Clinic, Rochester, New York
W illiam R. Dougherty, MD
Associate Professor of Surgery, Department of Plastic
Surgery,Vanderbilt University Medical Center,Vanderbilt
School of Medicine, Nashville,Tennessee
Ivica Ducic, MD, PhD
Associate Professor, Department of Plastic Surgery,
Georgetown University Hospital,Washington, DC
Loren H. Engrav, MD
Professor, Department of Surgery/ Plastic Surgery,
University of Washington, Seattle,Washington
R. Jobe Fix, MD
Professor, Department of Surgery, Division of Plastic
Surgery, University of Alabama at Birmingham,
Birmingham, Alabama
Leonard T. Furlow, Jr., MD
Clinical Professor, Department of Plastic Surgery,
University of Florida College of Medicine, Gainesville,
Florida
G. Mabel Gamboa-Bobadilla, MD
Associate Professor, Section of Plastic and Reconstructive
Surgery, Medical College of Georgia, Augusta, Georgia
Paul M. Gardner, MD
Associate, South Florida Plastic Surgery, Naples, Florida
Jacob Gerzenshtein, MD
Staff Plastic Surgeon, Department of Surgery, Division of
Plastic Surgery, Mercy Hospital, Janesville,Wisconsin
Robert M. Goldwyn, MD
Clinical Professor of Surgery, Harvard Medical School,
Boston, Massachusetts
James C. Grotting, MD
Clinical Professor, Division of Plastic Surgery, University
of Alabama at Birmingham; Private Practice, Grotting
Plastic Surgery, Birmingham, Alabama
M. Keith Hanna, MD
Paces Plastic Surgery, Atlanta, Georgia
Jeffrey M. Hartog, MD, DMD
Medical Director, Bougainvillea Clinique,Winter Park,
Florida
Paul S. Howard, MD
Associate Clinical Professor of Plastic Surgery, Depart-
ment of Surgery, University of Alabama at Birmingham,
Birmingham, Alabama
Kenneth B. Hughes, MD
Section of Plastic Surgery, University of Kansas Medical
Center, Kansas City, Kansas

Alison L. In eld, BA
Research Assistant, Department of Psychiatry, Center for
Weight and Eating Disorders, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania
Ian T. Jackson, MD, MD(G)(Hon), DSc(Hon), FRCS,
FRCS(G)(Hon), FRACS(Hon)
Director, Institute for Craniofacial and Reconstructive
Surgery; Division of Plastic Surgery, Providence Hospital,
South eld, Michigan
Glyn E. Jones, MD, FRCS(Ed), FCS(SA)
Associate Professor, Department of Plastic Surgery,
Emory Clinic, Atlanta, Georgia
Matthew B. Klein, MD
Assistant Professor, Burn Center and Division of Plastic
Surgery, University of Washington, Seattle,Washington
Gary S. Kopf, MD
Professor of Surgery, Section of Cardiothoracic Surgery,
Yale University School of Medicine, New Haven,
Connecticut
W.Thomas Lawrence, MPH, MD
Professor and Chief, Section of Plastic Surgery, University
of Kansas Medical Center, Kansas City, Kansas
Bradley K. Lewis, MD
Medical Director, Emergency Department/ Urgent Care
Medicine, After Hours Medical, Salt Lake City, Utah
W illiam C. Lineaweaver, MD
Professor, Department of Surgery, University of
Mississippi Medical Center, Jackson, Mississippi
Ernest K. Manders, MD
Professor of Surgery, Division of Plastic and
Reconstructive Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
Paul N. Manson, MD
Professor, Department of Surgery, Johns Hopkins
Hospital; Professor, Department of Surgery, University of
Maryland Shock Trauma Unit, Baltimore, Maryland
vii
Contributors
Victoria R. Masear, MD
Clinical Assistant Professor, Department of Orthopaedic
Surgery, University of Alabama at Birmingham,
Birmingham, Alabama
Clinton D. McCord, Jr., MD
Associate Clinical Professor, Department of Plastic
Surgery, Emory University, Atlanta, Georgia
Wyndell H. Merritt, MD
Clinical Professor, Department of Surgery, Medical
College of Virginia,Virginia Commonwealth University,
Richmond,Virginia
James R. Miller, MD
Assistant Clinical Professor, Department of Plastic
Surgery, Albany Medical College; Chief, Division of
Plastic Surgery, Albany Memorial Hospital, Albany,
New York
Joseph M. Mlakar, MD
Director, Burn Center, and Chief of Surgery, St. Joseph’s
Hospital, Fort Wayne, Indiana
Foad Nahai, MD
Plastic Surgeon, Paces Plastic Surgery, Atlanta, Georgia
Tanya M. Oswald, MD
Microsurgery Fellow, Department of Surgery, University
of Mississippi Medical Center, Jackson, Mississippi
Omer Re k Ozerdem, MD
Cosmetic Surgery and Breast Reconstruction Fellow,
Department of Plastic and Reconstructive Surgery,
University of Alabama at Birmingham, Birmingham,
Alabama; Associate Professor, Department of Plastic,
Reconstructive, and Aesthetic Surgery, Baskent
University, Ankara,Turkey
Silvio Podda, MD
Craniofacial Fellow, Department of Plastic and
Reconstructive Surgery, Miami Children’s Hospital,
Miami, Florida
Julian J. Pribaz, MD
Program Director, Harvard Plastic Surgery; Professor of
Surgery, Division of Plastic Surgery, Brigham and
Women’s Hospital, Boston, Massachusetts

viii
Contributors
Brunno Ristow, MD
Private Practice, California Paci c Medical Center;
Chief Emeritus of Plastic Surgery, Presbyterian Medical
Center, San Francisco, California
Rod J. Rohrich, MD
Professor and Chairman, Crystal Charity Ball Distin-
guished Chair in Plastic Surgery, Betty and Warren
Woodward Chair in Plastic and Reconstructive Surgery,
Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas,Texas
Eva Rubin, MD
Clinical Director, Breast Imaging, Department of
Radiology, Montgomery Radiology Associates,
Montgomery, Alabama
David B. Sarwer, PhD
Associate Professor of Psychology, Departments of
Psychiatry and Surgery, Center for Human Appearance,
Center for Weight and Eating Disorders, University
of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
R. Bruce Shack, MD
Professor and Chairman, Department of Plastic Surgery,
Vanderbilt University Medical Center, Nashville,
Tennessee
Jack H. Sheen, MD
Santa Barbara, California
Randy Sherman, MD
The Audrey Skirball Kenis Professor and Chair, Depart-
ment of Plastic and Reconstructive Surgery, University of
Southern California, Los Angeles, California
Sumner A. Slavin, MD
Associate Clinical Professor of Surgery, Department
of Surgery (Plastic), Harvard Medical School; Chief,
Division of Plastic Surgery, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
Richard S. Stahl, MD, MBA
Vice President, Ambulatory Services Division,Yale–
New Haven Hospital; Clinical Professor, Department of
Surgery,Yale University, New Haven, Connecticut
Stephanie A. Stover, MD
Associate, Nashville Plastic Surgery, Nashville,Tennessee
James M. Stuzin, MD
Assistant Professor of Surgery (Plastic),Voluntary, Univer-
sity of Miami School of Medicine, Miami, Florida
Helena O.B.Taylor, MD, PhD
Resident, Harvard Plastic Surgery, Boston, Massachusetts
Sumeet S.Teotia, MD
Private Practice, Charlotte Plastic Surgery, Charlotte;
Clinical Assistant Professor, Division of Plastic and
Reconstructive Surgery and Surgery of the Hand,
University of North Carolina, Chapel Hill, North
Carolina
Luis O.Vásconez, MD
Professor and Chief, Division of Plastic Surgery,
University of Alabama at Birmingham, Birmingham,
Alabama
Fausto Viterbo, MD, PhD
Professor and Chief, Department of Plastic and Recon-
structive Surgery, São Paulo State University/UNESP,
Botucatu, São Paulo, Brazil
Robert L.Walton, MD
Clinical Professor, Department of Surgery, Section of
Plastic Surgery, University of Chicago, Chicago, Illinois
Anne G.Warren, BA
Doris Duke Clinical Research Fellow, Department of
Surgery (Plastic), Harvard Medical School, Boston,
Massachusetts
S. Anthony Wolfe, MD
Chief, Department of Plastic and Reconstructive Surgery,
Miami Children’s Hospital, Miami, Florida
G. Jackie Yee, MD
Attending Plastic Surgeon, Baker Plastic Surgery, Miami,
Florida

To Ann, Jimmy, and Ben
and
To my mother, Shirley Grotting Lindemann,
and my father, John K. Grotting, MD (1915-1968),
who would have been awed by the tremendous advances in his beloved
specialty of plastic surgery, yet reassured to know that kind and
compassionate care of patients remains its foundation.

(Trang không có chữ)

xi
The specialty of plastic surgery has long served as an incubator for surgeons with
creativity and imagination. Ours is a discipline that continues to evolve, fueled by
innovation and an ongoing desire to re ne and improve our results. We are privi-
leged to be plastic surgeons at a time when we have so much to offer our patients.
In the 12 years since the publication of the rst edition of Reoperative Aesthetic &
Reconstructive Plastic Surgery, the world has witnessed the introduction of numerous
medical and technologic advances that have given us the tools to accomplish the
previously unimaginable. From face transplantation to tissue engineering, plastic
surgeons have been at the forefront of surgical innovation.The nature of what we
do demands open, fertile minds that dare—to “see,” to dream, and to implement
solutions for seemingly intractable problems. No area of plastic surgery demands
more creativity, ingenuity, and problem-solving skill than that of reoperative plas-
tic surgery.
It is gratifying to note that reoperative surgery, a subject that was little discussed
when the rst edition was published, is now increasingly a familiar theme in scien-
ti c publications, meeting panels, and program topics. The rst edition advanced
the concept of reoperative plastic surgery, providing a foundation for ongoing dis-
cussion. Now, after another decade of experience and directed thought about this
subject, we have crafted a second edition to continue the conversation and to ex-
amine lessons learned and new options currently available. It contains the latest in-
formation on this topic.
Regrettably, the topic of reoperative surgery does not always receive the attention
it deserves. Even experienced surgeons are sometimes reluctant to share lessons
learned from errors, unsatisfactory results, or complications. Yet it is exactly that
information that is most valuable to surgeons who have not yet encountered the
same conditions but may face them with the very next patient they see. The goal
of this book is to put this elusive knowledge at your ngertips. It is for this very rea-
son that the book has become a favorite among young plastic surgeons preparing
for their oral board examinations as well as experienced practitioners seeking in-
sight into dif cult cases or contemplating recerti cation
Although many basic plastic surgery principles remain solidly entrenched in these
freshly inked pages, there is much that is new. Anatomy has not changed—but our
understanding of anatomic relationships has evolved, enabling us to develop new
procedures and to re ne and improve old ones.
to the Second Edition
P r ef a ce

xii
Preface to the Second Edition
As with the rst edition, the book consists of two volumes comprising seven parts
arranged by anatomic region. All chapters have been revised, and there are 11 to-
tally new chapters that address topics such as endoscopic treatment of secondary
brow ptosis, staged procedures and reoperations following massive-weight-loss sur-
gery, secondary fat grafting, correction of postlipoplasty deformities, reoperative
head and neck reconstruction, reoperative lower lid blepharoplasty, and psycholog-
ical considerations for the reoperative patient.
I am joined by a group of expert contributors who have shared their experience in
reoperative situations to guide you, the reader, toward proven approaches, prevent-
ing strategic errors, and providing a ready resource for consultation. Authors from
the rst edition have carefully updated their material, adding new cases, deleting
concepts or procedures that they have abandoned, and providing insight into tech-
nical nuances that maximize and enhance long-term corrections. New contributors
have addressed topics that were underrepresented previously and those that are new
to this edition. It is helpful to remember that these new procedures are not neces-
sarily immune to the need for secondary surgery.
Throughout these pages, the emphasis is on surgical judgment and the clinical
problem-solving process that is critical to the successful execution of any reopera-
tive procedure. Many new features and hundreds of photographs, medical illustra-
tions, and clinical cases have been added to enhance the educational experience.To
improve the aesthetic appearance and facilitate understanding of the various oper-
ative sequences, the majority of illustrations and cases are now in color.The book
is lled with tips and tricks and surgical nuances to assist surgeons with developing
the nesse necessary to avoid complications in the pursuit of excellence. Each chap-
ter now includes multiple-choice board review questions, annotated references, key
points, and improved illustrated operative technique. Two DVDs with operative
video complement the book.
It is likely that these volumes will be consulted in bits and pieces—a few para-
graphs, a chapter, or a section at a time. However, I recommend that these chapters
be read early:“The Patient,”“The Surgeon,” and “What Is Reoperative Surgery?”
These will set the stage for the information that follows and help you gain perspec-
tive on the special problems associated with the reoperative patient before you are
confronted with a dif cult patient who is frightened, angry, or critically ill. It is
hoped that the information contained within these pages will prompt you to pay
closer attention to your own outcomes with secondary surgery and provide in-
sight into the techniques that have proven effective. Reoperative surgery is a chal-
lenging yet wonderfully rewarding endeavor. We hone our skills and sensibilities by
becoming expert in solving these interesting and complex problems.The ultimate
reward is enhanced results and improved outcomes for our patients, and an oppor-
tunity to advance the art and science of our specialty.
James C. Grotting

R eoperative plastic surgery assumes many guises in a plastic surgeon’s practice.
Although complications and salvage situations immediately come to mind when we
think of reoperative surgery, the scope is far broader. It is the staged procedure care-
fully planned to preserve blood supply or the finishing touch that transforms a
good result into a superlative one. Perhaps it represents a surgical intervention to
treat the recurrence of disease or the continued biologic changes of aging. It may
be the creative solution for improving an unsatisfactory result—the nemesis of all
surgeons. Whatever the de nition, much of our practice is reoperative in nature.
The thread of commonality uniting all reoperative surgery is that the plastic sur-
geon finds himself confronting tissue plans biologically altered by the effects of
wound healing. This challenge often demands more innovative solutions and
greater skill than the initial surgical intervention;it is more right brained than left,
more creative than analytic. Much like a chess game, strategic planning is the crit-
ical element de ning a successful outcome.
When faced with any dif cult problem, we typically turn to the literature and to
the masters who have preceded us to guide our way. In secondary surgery the an-
swers we seek are more elusive. Despite the complex nature of these procedures,
their artful execution and pitfalls have received scant attention in the literature.
Thus we often approach these secondary cases with surgical plans derived from
our own personal and anecdotal experience only to nd ourselves adrift without a
nautical chart or compass.
This book is in response to the need for a source of information to which to turn
when confronted with secondary problems—a synthesis if you will. Similar to the
travel clubs so popular in plastic surgery that have long been a rich source of shared
experience and verbal problem solving, this book culls the wisdom and clinical ad-
vice from a national and international group of expert contributors. It is an at-
tempt to draw on the cumulative experience of master surgeons to increase our
chances of obtaining a favorable result. It would serve us well to have a road map—
to know in advance that a brilliantly conceived plan may already have been clini-
cally applied with an unfortunate outcome because of unanticipated tissue failure
and to know that an alternative surgical approach would provide a safer, more ef-
fective solution. We have focused on those clinical conditions in which previous
surgery has resulted in signi cant tissue changes and in which secondary correction
requires an approach that differs from the primary plan. By analyzing reoperative
conditions, we seek to better understand the mechanisms by which they occur,
thus developing a strategy for avoiding problems and promoting favorable out-
xiii
to the First Edition
P r ef a ce

xiv
Preface to the First Edition
comes.We also attempt to capture the surgical artistry and vision that enable expe-
rienced surgeons to produce unparalleled results.
The contributors to this book were carefully selected for their technical skill, their
innovative approach to problem solving, and their extensive experience in a partic-
ular area.These chapters represent each author’s personal approach to speci c sur-
gical conundrums. A virtual gold mine of untapped information is contained
within their results, taking the reader through the critical planning process essen-
tial to achieving superior results.The perspective of each chapter is dictated by its
unique subject matter. Some chapters address primarily complications. Others dis-
cuss staged procedures, whereas others examine a mix of problems and planned re-
visions. Some chapters focus on one clinical case and use it as a springboard to dis-
cuss a wide range of problems, whereas others contain numerous case examples to
highlight individual anatomic challenges.
The scope of this book is both aesthetic and reconstructive; the distinction be-
comes blurred in the reoperative setting.The 47 chapters are divided into seven sec-
tions starting with the reoperative environment and basic issues of scarring, tissue
movement and transplantation and then proceeding anatomically to investigate spe-
ci c reoperative problems of the head and neck, breast, chest wall, trunk and ex-
tremities. To make the reading process as smooth as possible, text and illustrations
are in close proximity to each other. Hundreds of patient examples and operative
sequences have been described and illustrated in color to assist the reader in under-
standing the nuances of various operative approaches.
One of the primary criticisms levied against any contributor work is the uneven-
ness and overlapping of material from one chapter to another. A concentrated ef-
fort was made to obviate this problem by providing a basic format and structure to
shape the authors’presentations and by investing enormous time and effort writ-
ing my own chapters and editing others to ensure a consistent approach. Notwith-
standing these guiding principles, the contributors had the freedom to vary the
format when the topic so dictated. In addition, to facilitate the learning process,
some overlap still remains when the information is integral to the understanding of
a problem or a clinical description. Every attempt was made, however, to retain the
author’s personality and distinctive style. The wit and individual style displayed by
each contributor permit the reader a rare insight into the creative spirit that guides
the scalpel.
As the writing process draws to a close, my initial enthusiasm and vitality begin to
resurface. I trust that this legacy will be worth the sacri ces and the stolen mo-
ments from family and practice. My desire is that the reader and patients will be the
bene ciaries of this rst attempt to harvest the collective wisdom from those who
have risen to the challenge of reoperative surgery.
James C. Grotting

xv
This book represents the combined contributions of many of the world’s most
gifted surgeons who have generously shared their experience and wisdom with
colleagues in the United States and abroad.They have done so unsel shly, stealing
time away from their families and their practices to translate their thoughts into
the written word. I am indebted to them for their participation in this endeavor and
their encouragement throughout. Their positive feedback about how this writing
experience has contributed to their professional growth has been a prime motiva-
tor for me throughout the writing and editing process. Hopefully this writing as-
signment has challenged them to think about reoperative surgery in new ways that
may not have been evident to them before they were invited to put pen to paper
(or ngers to keyboard). I am also grateful to readers of the rst edition who have
provided an ongoing stream of insightful suggestions for improving the organiza-
tion and content of these volumes.
I am deeply indebted to a team of publishing professionals whose concentrated ef-
forts have nurtured this edition of Reoperative Aesthetic & Reconstructive Plastic Surgery
from concept to reality. As before, it has been the relentless and determined en-
ergy of Karen Berger and her outstanding team at Quality Medical Publishing who
have pushed this project along, with careful thought given to every detail that
makes a book like this enjoyable and readable.Who but Karen would be willing to
grind out paragraph after paragraph with me in the solitude of her of ce at 1:30 AM
on a Sunday morning in July after working for 30 straight hours with minimal rest!
I would like to speci cally thank and acknowledge the other members of the QMP
family here. Suzanne Wake eld, Director of Editing, played an enormous role as
project manager, editing the entire manuscript along with Becky Sweeney and
Donna Rothenberg. Michelle Berger, Editor, oversaw the organization and pro-
cessing of the project and Amy Debrecht, Assistant Editor, checked in each chap-
ter and each gure to ensure accuracy and completeness. Reproduction of images,
graphics, and medical illustrations is really what constitutes the beauty of a textbook
like this one. Amanda Behr, Director of Medical Illustration, and Jennifer Gentry
served as the tremendously talented medical illustrators whose work is seen through-
out the book. Brett Stone, Graphics Technician, handled all the color correction and
coordinated the electronic les of images while Sandy Hanley scanned all of the
images to be used from the rst edition. Carolyn Reich, Director of Manufactur-
ing and Production, oversaw all layout and page proof production, coordinated the
cover of the book, and supervised the printing and manufacturing of the book.
Layout artists Susan Trail and Elaine Kitsis, sized all the images, typeset the manu-
A ck n ow l ed gmen t s

xvi
Acknowledgments
scripts, and created the visually attractive appearance of each page.Throughout the
process, Andrew Berger has been tremendously supportive, running me back and
forth to the Spirit of St. Louis airport and crafting plans for the marketing and sales
of the book.
On the home front, I could not have completed this project without the staff of
Grotting Plastic Surgery in Birmingham. My dedicated of ce team has played a
vital role every step of the way. Nanette Rasberry, Of ce Manager, coordinated the
communication and transfer of all materials between our of ce and QMP. Martha
Garrison, Clinical Coordinator, and Jennifer Tatum, RN, spent countless hours
contacting patients for postoperative follow-up and handled the processing of dig-
ital images for many of the chapters. Their personal attention to detail is apparent
throughout the book.Vicki Goldstein, Patient Care Coordinator, managed my sur-
gical and travel schedules to allow for the necessary trips back and forth to St. Louis
to complete the project. Dr. Al Cohn, our 2006-2007 plastic surgery fellow, has
been invaluable as a chapter contributor, question writer, and nal proof editor for
much of the book. Each of these individuals has given of their time and talent to
help this book reach its full potential.
I would like to acknowledge the exceptional talent of William Hook, who painted
the work that adorns the cover of this book and is pictured above.When Ann and
I rst saw this painting, we knew immediately that we wanted it to hang in our per-
sonal collection.To us, it is a metaphor for Reoperative Aesthetic & Reconstructive Plas-
tic Surgery. If one envisions the challenge of reoperations in our specialty as a little
like being “lost in the woods,” then perhaps this book can be “the clear path” out—
at least that is our hope! With luck, great results and grateful patients will await us
Over the Hill!
Finally, I want to thank my beautiful and loving wife, Ann, and my sons, Jimmy
and Ben, for their unwavering support and encouragement during the writing of
this book, which they have come to accept as our constant companion over the past
several years. So many late nights and absent weekends have stolen my attention
away from those whom I so dearly love. Yet, even as I write these words, I know
that they are proud of the critical supportive role they have played in helping me
to create a work that hopefully will provide a lasting contribution to plastic surgery.

xvii
C on t en t s
THE R EOPERATIVE ENVIRONMENT
1
What Is Reoperative Plastic Surgery?
3
James C. Grotting
2
The Patient
35
James C. Grotting
3
Psychological Considerations in Reoperative Plastic Surgery
Patients
55
David B. Sarwer,Alexander W. Baker, and Alison L. In eld
4
The Surgeon
77
Robert M. Goldwyn
SCARS,TISSUE MOVEMENT, AND
TRANSPLANTATION
5
Common Secondary Complications
89
James C. Grotting
6
Scars and Scar Revision
113
Kenneth B. Hughes and W.Thomas Lawrence
7
Reoperation for Donor Site Complications
147
James C. Grotting and Grady B. Core
P a r t I
P a r t II
VOLUME I

xviii
Contents
8
Repeated Tissue Expansion
175
Ernest K. Manders and Paulo da Paula
9
Failed and Failing Free Flaps
195
William C. Lineaweaver, Stephanie A. Stover, and Jacob Gerzenshtein
R EOPERATIVE SURGERY OF THE
HEAD AND NECK
Facial Rejuvenation
10
Milestones in the Evolution of Face-Lift Techniques
219
Brunno Ristow
11
Reoperative Rhytidectomy
257
James C. Grotting and James M. Stuzin
12
Reoperative Forehead Lift
309
Brunno Ristow
13
Use of Endoscopy in Reoperative Brow-Lifting
333
Jorge I. de la Torre and Luis O.Vásconez
14
Adjunctive Surgical Procedures to Improve the
Face-Lift Result
347
G. Mabel Gamboa-Bobadilla, Omer Re k Ozerdem, and Luis O.Vásconez
15
Adjunctive Procedures to Improve the Results in Facial
Aesthetic Surgery
377
Tracy M. Baker and G. Jackie Yee
16
Revisional Fat Grafting of the Cheek and Lower Eyelid
403
Sydney R. Coleman
P a r t III

xix
Contents
Surgery of the Eyes, Nose, and Ears
17
Reoperative Blepharoplasty
441
James H. Carraway, James R. Miller, and Bradley K. Lewis
18
Reoperative Lower Lid Blepharoplasty
481
Mark A. Codner and M. Keith Hanna
19
Secondary Ptosis Correction
513
James H. Carraway, James R. Miller, and Bradley K. Lewis
20
Reoperation and Avoidance and Treatment of Complications
in Eyelid Surgery
545
Clinton D. McCord, Jr., and Foad Nahai
21
Secondary Rhinoplasty
595
Rod J. Rohrich, Jack H. Sheen, and Sumeet S.Teotia
22
Reoperative Surgery for Nasal Reconstruction
705
Gary C. Burget, Dean E. Burget, Jr., Elisabeth K. Beahm, and Robert L.Walton
23
Staged Sequential Procedures for Ear Reconstruction
759
Bruce S. Bauer
Head and Neck Reconstruction
24
Surgery for Recurrent Cutaneous Malignancies of the
Head and Neck
801
Grant W. Carlson
25
Reoperative Issues Following Flap Reconstruction in the Head
829
Julian J. Pribaz and Helena O.B.Taylor
26
Secondary Procedures in Facial Reanimation
859
Fausto Viterbo and Adel Hussein Amr
27
Primary Care and Secondary Reconstruction of the Burned
Face and Neck
881
Loren H. Engrav and Matthew B. Klein
28
Reoperative Facial Fracture Repair
903
Paul N. Manson

xx
Contents
Craniomaxillofacial Surgery
29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal
Deformity
1013
Ian T. Jackson
30
Secondary Cleft Palate Surgery
1053
Leonard T. Furlow, Jr.
31
Reoperative Craniomaxillofacial Surgery With Emphasis on
Alloplastic Failure
1113
S.Anthony Wolfe, Paul S. Howard, Silvio Podda, and Jeffrey M. Hartog
32
Reoperative Craniomaxillofacial Surgery
1139
Ian T. Jackson
R EOPERATIVE SURGERY OF THE BREAST
AND CHEST WALL
33
Reoperative Breast Surgery After Reduction Mammaplasty
and Mastopexy
1197
James C. Grotting and Carl C.Askren
34
Reoperative Surgery Following Breast Augmentation
1261
James C. Grotting, Paul M. Gardner, and Alvin B. Cohn
35
Reoperation Following Implant Breast Reconstruction
1317
James C. Grotting
36
Finishing Touches After Breast Reconstruction With
Pedicled Flaps
1365
Glyn E. Jones and John Bostwick III
37
Reoperation Following Free Flap Breast Reconstruction
1411
James C. Grotting
P a r t IV
VOLUME II

xxi
Contents
38
Imaging Considerations in Plastic Surgery of the Breast
1481
Eva Rubin and Stamatia V. Destounis
39
Local Recurrence After Mastectomy and Breast
Reconstruction
1511
Sumner A. Slavin and Anne G.Warren
40
Reoperative Surgery of the Chest Wall
1525
Richard S. Stahl, Gary S. Kopf, and Simon H. Chin
R EOPERATIVE SURGERY OF THE TRUNK
41
Reoperative Liposuction
1601
Kristoffer Ning Chang
42
Reoperation After Liposuction and Body Contour Surgery
1635
Ricardo Baroudi
43
Staging, Reoperation, and Treatment of Complications After
Body Contouring in the Massive-Weight-Loss Patient
1701
Al S.Aly and Joseph F. Capella
44
Reoperative Surgery of the Abdominal Wall
1741
Grady B. Core and James C. Grotting
45
Treatment of Recurrent Pressure Sores
1825
R. Jobe Fix
R EOPERATIVE SURGERY OF THE EXTREMITIES
46
Reoperative Hand Surgery
1863
Wyndell H. Merritt and Victoria R. Masear
47
Secondary Surgery Following Digit Replantation
1939
William C. Lineaweaver and Tanya M. Oswald
48
Reoperative Surgery After Excision and Grafting of Upper
Extremity Burns
1963
William R. Dougherty, Joseph M. Mlakar, and R. Bruce Shack
P a r t V I
P a r t V

xxii
Contents
49
Reoperative Peripheral Nerve Surgery
1985
Ivica Ducic,A. Lee Dellon, and Ali Al-Attar
50
Reoperative Surgery Following Tissue Transplantation in Extremity
Reconstruction
2009
Randy Sherman
IN CLOSING
51
In Closing
2061
James C. Grotting
Credits
C1
Answer Key to Review Questions
A1
Index
I1
P a r t V II

&
AESTHETIC
R ECONSTRUCTIVE
PLASTIC SURGERY

(Trang không có chữ)

THE REOPERATIVE
ENVIRONMENT
P a r t I

(Trang không có chữ)

3
W hat Is Reoperative Plastic Surgery?
James C. Grotting
C ha pter 1
Reasons for Reoperation
Planned reoperation
Recurrence of disease
Less than satisfactory outcome
Continued biologic processes
Re nements or touch-ups
Complications
But no perfection is so absolute,
that some impurity doth not pollute.
William Shakespeare
R eoperative plastic surgery de es clear-cut de nition.The full spectrum of aes-
thetic and reconstructive challenges is represented. Although complications natu-
rally come to mind when one thinks of reoperative surgery, in actuality much more
is involved.The nishing touches after a breast reconstruction, correction of a dor-
sal irregularity after primary rhinoplasty, evacuation of a hematoma after a face lift,
salvage of a failing free ap, or reoperation for a recurrent sagging jowl 10 years af-
ter primary rhytidectomy represent the diversity encountered in these demanding
and challenging surgical interventions. Secondary surgery includes planned steps in
a staged procedure and aesthetic re nements necessary to perfect the result of a
previously successful operation. All of these situations may mandate reoperation.

4
PART I
THE R EOPERATIVE ENVIRONMENT
The many circumstances potentially requiring reoperation appear to be signifi-
cantly different; however, closer examination reveals common elements. Whether
treating patients with complications or those in whom revisions or staged proce-
dures are necessary, the plastic surgeon deals with tissue planes that have been sub-
jected to the biologic effects of wound healing.The scalpel alters intrinsic anatomic
relationships, isolates and compartmentalizes zones of perfusion, and produces in-
jury that results in scars.
Guiding principles for the reoperative surgeon are dif cult to uncover in the med-
ical literature. In terms of complications and unsatisfactory results, there is a natu-
ral tendency for surgeons not to report their misadventures or shortcomings even
though great ingenuity was required to solve a particular problem or salvage a re-
sult. In addition, as surgeons mature in their profession, they may precipitate fewer
of their own patients’needs for reoperation but will likely continue to address prob-
lems created by others. Ideally, this is the natural history of self-education by expe-
rience. Nevertheless, no surgeon ever becomes exempt from facing unanticipated
reoperative situations in his or her own patients. As is often stated, surgeons who
boast that they never have any complications are either lying or have stopped op-
erating! However, the principles of reoperative surgery are communicated among
us frequently in “curbside consultations,” late night telephone calls, or conversa-
tions in surgeons’lounges.They have become part of the orally transmitted surgi-
cal lore rather than the recorded word. An experienced senior surgeon may have a
wealth of knowledge regarding techniques for handling problem conditions, yet
may be reluctant to commit that knowledge to the written word.
THE SPECTRUM OF REOPERATIVE SURGERY
PLANNED R EOPERATION
Many plastic surgery procedures include second and third operations as part of the
overall reconstructive plan. Breast reconstruction by tissue expansion followed by
the insertion of a permanent prosthesis and inframammary fold adjustment is one
such plan that deliberately involves multiple procedures. Although secondary pro-
cedures may be brief in duration and may even be performed with the patient un-
der local anesthesia on an outpatient basis, the proper execution of the procedure
is often absolutely critical to the overall success of the result. For example, the di-
vision and inset of a transferred pedicle ap represents a planned reoperation. One
might ask oneself,“Should the pedicle be divided at this time or should this wait a
bit longer? Should the pedicle be completely divided, or should it be divided in
stages? Can the ap be thinned and re ned now or should yet another reoperation
be planned?” These important considerations must be addressed before what oth-
erwise may seem to be a very simple secondary procedure can be performed.

5
Chapter 1
What Is Reoperative Plastic Surgery?
This 16-year-old girl was brought in by her parents for surgical correction of
Poland’s syndrome.
Before surgery she had been using the external prosthesis shown (right).
The reconstructive plan was to place a tissue expander in the subcutaneous plane
to create an adequate space for a future free transverse rectus abdominis muscle
(TRAM) ap.The expansion was carried out over a 3-month period.

6
PART I
THE R EOPERATIVE ENVIRONMENT
The surgical plan for the free TRAM ap is outlined.This ap was chosen because
of the desire for permanent breast reconstruction and the requirement for adequate
volume replacement, including the tail of the breast area.
Three months after the free TRAM
ap procedure, the patient has a stable
reconstruction. The skin island moni-
tor is visible at the lateral edge of the
inframammary incision used to insert
the ap.
The patient returned 10 years later after having married, becoming a registered
nurse, and having two children. She desired further corrections to equalize the size
and shape of her breasts.

7
Chapter 1
What Is Reoperative Plastic Surgery?
A staged revision was planned. In the rst stage the skin island monitor from the
free TRAM was excised, deepithelialized, and transplanted as a dermal fat graft to
augment the still de cient tail of the breast area.
A small periareolar mastopexy was performed on the slightly ptotic left side to di-
minish the distance the right nipple would have to be moved inferiorly.

8
PART I
THE R EOPERATIVE ENVIRONMENT
Additional autogenous fat grafting was done to supplement the tail of the breast
area.The immediate intraoperative result is shown.
A considerable challenge was to further move the right nipple inferiorly.This was
done by creating an “inchworm” ap to increase nipple size and move the native
nipple inferiorly. A small graft taken from the opposite areola was placed on the
donor site.

9
Chapter 1
What Is Reoperative Plastic Surgery?
The reconstruction was completed with areolar tattooing 3 months after the right
nipple transposition.
This sequence of planned and staged reconstructive procedures illustrates the
essence of reoperative plastic surgery. Each stage needed to be carefully planned
and executed so as not to sacri ce valuable native tissue, and further, not to over-
stress the tissues to avoid complications. Obviously, a reconstruction carried out
over 12 years requires an optimistic and understanding patient as well as carefully
considered plastic surgery execution.
The components of success include a clear plan of the primary pro-
cedure and the reoperation, good technical execution, and a well-
informed patient.

10
PART I
THE R EOPERATIVE ENVIRONMENT
LESS THAN SATISFACTORY O UTCOME
An outcome that does not achieve all of the goals for the procedure is a frequent
reason for reoperation, particularly early in a surgeon’s career. Ideally, with experi-
ence surgeons are able to achieve the anticipated outcome the rst time around in
a greater percentage of cases. However, no surgeon is able to “hit it just right” 100%
of the time. It is a commonly accepted observation that reoperation rates go up
following national plastic surgery meetings. Returning surgeons may elect to try out
a newly acquired technique before they are equipped with the judgment that
comes with experience.Therefore part of every preoperative consultation should be
the careful discussion of what will be done if either the patient or the surgeon is not
satis ed with the result. In some cases a revision of this type will be entirely elec-
tive and left to the patient’s discretion. In other situations, such as recurrent airway
obstruction following septoplasty, the patient may be compelled to undergo reop-
eration to correct functional problems.
This 17-year-old woman is an example of a patient with persistent problems fol-
lowing a primary procedure. She was involved in an automobile accident in which
she sustained a through-and-through laceration of the left eyelid and brow. The
initial repair included the placement of a small postauricular graft to replace what
was perceived as the tissue de cit. Postoperatively the persistent deformity—the
inability to fully close the left eye—was apparent. The revision included the wide
re-creation of the initial defect and release of the skin from the underlying orbic-
ularis oculi muscle. A second postauricular graft placed as an aesthetic unit allowed
complete eye closure.
R EFINEMENTS OR TOUCH-UPS
A reoperative procedure to re ne a previous surgery is usually purely elective and
the outcome satisfying for both surgeon and patient. However, surgical touch-ups
can be tremendously challenging for the surgeon in attempting to devise ways to
shape the tissues, improve aesthetic form, and achieve a more natural appearance. It
is not uncommon to encounter patients who will continually pressure the plastic

11
Chapter 1
What Is Reoperative Plastic Surgery?
surgeon for multiple additional improvements, particularly if a third-party payor is
covering the cost. Of course, currently, these repeated re nements are more dif -
cult to justify to insurance carriers. Therefore patients may temper their demands
for further improvements if they must bear the cost.
A 41-year-old woman who had lost 120 pounds following gastric bypass surgery
presented for correction of ptotic atrophic breasts.
The surgical plan was to perform an
augmentation mastopexy through a
vertical approach using saline implants
in the subpectoral position. The supe-
riorly based parenchymal flap was
folded beneath the upper pole.

12
PART I
THE R EOPERATIVE ENVIRONMENT
The 8-day result and the 2-month photo demonstrate bottoming out of the im-
plants, particularly on the right side.
The reoperative re nement (left) required internal capsulorrhaphy of both breasts to
resupport the implant.This revision was carried out in the of ce with the patient
under local anesthesia, at minimal expense. The 6-month postoperative result is
shown (right).
R ECURRENCE OF DISEASE
When a disease process leads to a primary surgery, it can also be involved in creat-
ing the necessity for reoperation. Recurrent scarring or keloid formation is one
example.The recurrence of a cancer is one of the more prevalent reasons for reop-
eration. In the past the only treatment alternatives for locally recurrent cutaneous
malignancies involving critical structures were radiation and chemotherapy. Im-
provements in immediate ap reconstruction now allow a more aggressive surgical
approach to the excision of these aggressive, recurrent tumors.

13
Chapter 1
What Is Reoperative Plastic Surgery?
Treatment of recurrent aggressive skin cancers may require orbital exenteration and
subsequent major reconstructive procedures. This 64-year-old woman presented
with the third recurrence of a basal cell carcinoma in the right temporal and lateral
canthal area. A CT scan showed invasion into the orbit involving the extraocular
muscles. A much more aggressive surgical plan was mandatory.
Orbital exenteration was performed through a bicoronal approach with frontal
craniectomy. A template of the planned skin resection was used to design a rectus
abdominis musculocutaneous ap to ll the defect.

14
PART I
THE R EOPERATIVE ENVIRONMENT
CONTINUED BIOLOGIC PROCESSES
Aging is the best example of this cause for reoperative surgery. Frequently, patients
who present for this reason have had previous satisfactory outcomes from their sur-
gery but some years later request additional correction to offset the effects of aging.
The recurrence of breast ptosis following an initial mastopexy with a satisfactory
outcome is such an instance. Reoperating under these circumstances involves spe-
cial considerations and pitfalls. Patients are most able to accept the need for reop-
eration in this circumstance if they have been well counseled regarding the natural
aging process in advance of the primary procedure.
Radiation produces tissue effects that are destructive and progressive over many
years. This 32-year-old woman presented 2 years after undergoing a left modi ed
radical mastectomy and immediate conventional TRAM ap reconstruction of her
left breast. A decision was made to irradiate her breast and chest wall as adjunctive
treatment for her breast cancer. The TRAM ap became brotic, contracted, and
painful at 2 years after radiotherapy.

15
Chapter 1
What Is Reoperative Plastic Surgery?
The reconstructive plan required introduction of healthy vascularized tissue, since
it was not possible to expand this mass with a tissue expander or implant alone. A
large latissimus dorsi musculocutaneous ap was mobilized to cover the deepithe-
lialized and debrided TRAM ap, which was left as a central “autogenous” implant.
The inframammary fold was signi cantly lowered and a further reduction was ac-
complished on the right side.
With the addition of a small implant secondarily to lower the inframammary fold
and nipple reconstruction, a stable reconstruction was achieved 2 years postopera-
tively.

16
PART I
THE R EOPERATIVE ENVIRONMENT
COMPLICATIONS
Although all operations carry the risk of complications, only some of these prob-
lems require operative management. Complications, of course, have signi cant ram-
i cations for both the patient and the surgeon. In many cases, such as an expand-
ing hematoma or failing microsurgical anastomosis, there is an urgent need to act
expeditiously.The reoperative surgeon may not have the luxury of time to consult
with colleagues, review published journal articles and books, or return to the ca-
daver laboratory to practice. He or she must quickly formulate the reoperative plan
and execute it immediately.
Hematoma is a complication common in all elds of surgery.When it occurs fol-
lowing an aesthetic procedure such as a breast augmentation, its consequences ex-
tend beyond the local tissue affects.This healthy 34-year-old woman presented for
elective breast augmentation.Three days postoperatively she suddenly experienced
pain, swelling, and a bluish discoloration of her left breast after physical exertion.
Prompt reexploration and evacuation of the hematoma ultimately resulted in a sat-
isfactory outcome.

17
Chapter 1
What Is Reoperative Plastic Surgery?
Complications, of course, can manifest early or late in the postoperative period.
They may involve only the anatomic areas operated on (for example, wound dehis-
cence, skin graft loss) or they may be generalized (for example, systemic sepsis, pul-
monary failure). Complications are frequently precipitated by technical errors but
also result from tissue failure or host factors. In any event, treatment must balance
the cause of the complication against the risk of compounding the problem by any
additional intervention. For example, the surgical plan for treating a hematoma is
well known:it must be drained. But, determining the underlying cause is the more
important issue. Did the hematoma stem from a small bleeding vessel now harm-
lessly thrombosed or did it result from a ruptured microaneurysm because a criti-
cal microsurgical anastomosis was made to recipient vessels damaged by previous ra-
diation? Clearly these two “simple” hematomas require dramatically different
reoperative plans even though the clinical presentation appears similar.
THE REOPERATIVE PLAN
Surgery is a combination of planning and execution.With reoperative surgery the
surgeon is challenged in both arenas, because the decision-making process and the
handling of tissues become more complex. Reoperative plastic surgery demands
careful clinical analysis and judgment. Previously altered tissues leave scant room for
error. How will the circulation to the tissues be affected after reelevation? Will skin
elasticity be diminished? Will tissue transposition or rotation be possible without
undue tension? What does this patient expect the surgery to achieve and will it be
possible to satisfy him? All of these elements must be factored into the planning
process. Furthermore, it is crucial that the surgeon consider all potential problems
that could lead to failure, since the incidence of complications at this stage is higher
than that with primary surgery.
The reoperative surgeon must assess the degree of anatomic distortion, nature and
consistency of the scar, scope and condition of the involved anatomic area, and
availability of healthy surrounding tissue.The reoperative plan will emerge from the
synthesis of all of these factors. The physician-patient relationship also has an im-
pact on what will be done and how soon. The same reoperative condition in two
different patients might be treated in vastly different ways, depending on the wound
maturation process, associated medical problems, and patient expectations.
With secondary surgery the reoperative plan assumes special importance.Whether
this surgical intervention is dictated by an untoward result or is part of a staged
procedure or re nement, the goals are to correct the problem or defect, avoid re-
currence of problems, and prevent the creation of new complications.Therefore the
surgical plan must be carefully formulated to address all of the issues that might
impact the outcome.

18
PART I
THE R EOPERATIVE ENVIRONMENT
Dr. Luis Vásconez teaches residents, “If plan A did not work, do not
make plan B the same as plan A.”
Creativity rather than rote duplication of previous surgical efforts is essential to
success. This is especially true if the reoperative surgeon is not the same surgeon
who implemented plan A. Reoperative surgeons must avoid the mistake of believ-
ing that their own skills are so superior that they will not fall into the same traps.
Poor technique may not have been at fault. Many times it is not a poorly trained
surgeon but a poorly prepared surgeon who is the root of the problem. Although
occasionally choice of a surgical technique can doom a procedure, more often than
not it is the surgical plan that was de cient.
HOW REOPERATIVE SURGERY DIFFERS
FROM PRIMARY SURGERY
GOALS
Of necessity, the goals of reoperative surgery are more limited and focused than
those for primary surgery.The limitations of technology and tissue tolerance carry
their own restrictions. When multiple procedures are required, the surgeon must
help the patient to understand why total correction cannot be achieved in a single
operation. False hopes need to be dispelled to avoid further disappointment in a pa-
tient who may already be frustrated by previous surgical misadventures or short-
comings.
SCARRING1
Reoperative surgery is almost always performed through or around previous inci-
sions. Prior scars may dictate a surgical approach that is less than optimal for ideal
exposure. Reduction of overall scarring or preservation of circulation and innerva-
tion may mandate such a trade-off. When scarred tissue is incised, it often has a
greater tendency to retract, making secondary closure dif cult or impossible with-
out undue tension.This principle is particularly true when burned skin is incised;
in this situation the surgeon must be prepared to transfer new tissue to the opera-
tive site or to use skin grafts for wound closure.These differences in the tissue must
be anticipated so that the surgeon is not forced into intraoperative crisis manage-
ment.

19
Chapter 1
What Is Reoperative Plastic Surgery?
Residual deformities are common fol-
lowing the primary treatment of burns
by excision and skin grafting. In this
patient, severe burn scar contracture of
the neck resulted despite primary exci-
sion and grafting.
Release of the contracture caused an enormous defect, which was treated with a
sheet graft. Ultimately, satisfactory contour and release of the secondary burn scar
deformities were obtained using Z-plasties for the webs and placing additional sheet
grafts.
A surgical incision sets into motion a series of physiologic and biochemical events
that affect wound healing.1,2 This process culminates in the formation of scar.The
visible scar at the skin surface represents only the most super cial edge of a sheet
of collagen scar that extends into all tissue interfaces created by dissection and ele-
vation during surgery.The injury produced by surgery results in some degree of tis-
sue destruction as a result of direct injury and secondary atrophy. Delicate tissues
such as fat and endothelium are particularly vulnerable. As neutrophils and
macrophages initiate wound healing, cellular debris is carried away and replaced
by collagen. With time, the initial proliferative phase is followed by a maturation
phase, with softening and thinning of the scar (see p. 27). As this process occurs, pre-
viously elevated tissues may thin, resulting in a slightly atrophic area.

20
PART I
THE R EOPERATIVE ENVIRONMENT
This interesting 58-year-old patient presented with near-lifelong scarring that had
resulted from a childhood infection. She had been treated at the Mayo Clinic 50
years earlier. She brought in this photo (top) following multiple debridements and
skin grafting for what appeared to be actinomycosis.The disease process had left her
with severe scarring and contracture of the submandibular area on the right side,
extending along the preauricular area and temporal hairline.

21
Chapter 1
What Is Reoperative Plastic Surgery?
Careful excision of the scar and mobilization of nearby normal skin allowed im-
provement via a cervicofacial rotation ap and direct closure of the neck defect. A
SMAS face lift was done on both sides, as well as upper and lower blepharoplasties.
The nal result is shown 1 year postoperatively.

22
PART I
THE R EOPERATIVE ENVIRONMENT
Previously undermined skin will usually have a radically altered blood supply. Fas-
ciocutaneous or musculocutaneous perforators may have been divided, converting
the skin perfusion pattern to a large random subdermal network. An ill-planned in-
cision for a secondary procedure might precipitate ischemic strangulation of an
isolated perfusion zone. Similarly, if the reoperative plan includes the use of an ax-
ial ap, the surgeon must be certain that the axial vessel was not sacri ced previ-
ously.This situation is particularly problematic in the case of elevation of a fascio-
cutaneous flap in an area of previous undermining. As a result of a diminished
blood supply, previously elevated or incised tissue may be less tolerant of tension
and more vulnerable to disruption or infection.
Divided fasciocutaneous
perforators
Divided musculocutaneous
perforators
Random pattern of
subcutaneous plexus
Previously elevated flap
replaced in bed
No ingrowth from either the
previously divided musculocutaneous or
fasciocutaneous perforators
Preservation of subcutaneous
plexus as only source
of blood supply

23
Chapter 1
What Is Reoperative Plastic Surgery?
The scalpel also alters anatomic relationships. Once supporting structures are di-
vided, scar contracture, gravitational pull, and settling of tissues may result in gross
distortion of formerly closely related structures. For instance, multiple intraoral pro-
cedures were performed in this patient to treat a nonunion of a mandibular fracture.
Reoperation resulted in intraoral scarring, ptosis of the soft tissues, and disinsertion
of the supporting musculature of the chin and lower lip.The soft tissues and mus-
cles were reelevated and secured with permanent sutures fastened to drill holes in
the mandible just beneath the tooth roots.The tissues were then supported with an
external compression garment for 4 weeks.This correction resulted in the satisfac-
tory restoration of the anatomic relationship between the chin musculature, lower
lip, and jaw.The patient demonstrates considerably less lip strain following second-
ary reconstruction.
Preoperative view shows
unsupported lower lip
Postoperative view after resuspension
of chin soft tissue
ALTERED ANATOMIC R ELATIONSHIPS

24
PART I
THE R EOPERATIVE ENVIRONMENT
ALTERED TISSUE CHARACTERISTICS
Plastic surgeons are keenly aware that previously operated tissues respond less pre-
dictably than normal tissues. Surgery inevitably creates scarring, and scarring alters
the quality of normal tissue. Any surgeon who has redissected the tip cartilages of
the nose in a secondary rhinoplasty patient is acutely aware of how the tissues
change as the result of the primary surgery: there is a loss of the normal delicate
supporting structures around the cartilage as well as a softening of the cartilage it-
self.The same changes occur in skin, muscle, bone, and fat to a greater or lesser ex-
tent.When skin has been previously undermined, it loses some of its pliability, elas-
ticity, and ability to hold moisture. The skin simply does not move as well. If the
surgeon fails to consider the altered state of the tissues when formulating his plan
for secondary surgery, he may be faced with intraoperative surprises that he is ill-
equipped to handle.
Another factor contributing to altered tissue characteristics is denervation. This
process is most destructive in muscle but also affects fat and skin. Surgeons will
usually cautiously avoid damaging motor nerves but will often sacri ce small sen-
sory branches indiscriminately. Loss of the sympathetic innervation to the skin af-
fects the delicate vasomotor responses of the sweat glands and capillary beds and can
induce thinning, dryness, and loss of pliability. More controversial is the effect of
denervation on wound healing, which has been the subject of many studies con-
ducted in both experimental animals and humans. To some degree these changes
also occur in locally denervated tissue. Reinnervation may occur in nonanatomic
patterns.Therefore, in reoperations involving tissues that were previously manipu-
lated surgically, reinjury of small nerve twigs with resultant additional atrophy and
scarring is to be anticipated.The effect may be subtle, or it may be quite marked.