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75% improvement, and 100% of scars had greater than 50% improvement by pho-
tographic analysis.They also noted that elevated scars improved more dramatically
than depressed scars. Similar ndings with high-energy, pulsed and scanned CO2
lasers on atrophic scars resulting from acne, surgery, or trauma were reported by
West35 and Nehal et al.36
YAG LASER
Wavelength-speci c lasers (yttrium-aluminum-garnet and pulsed dye lasers) have
been used to selectively ablate blood vessels and thereby limit erythema and facil-
itate scar attening and maturation. Abergel et al37 reported attening and soften-
ing in scars in eight patients treated with the YAG laser with 3-year follow-up.
They postulated that the treatment produced an inhibition of broblast functions.
A recent study of 36 patients by Kwon and Kye38 showed that the pulsed YAG laser
is an effective and safe treatment option for hypertrophic and depressed scars.
Twelve of these patients were treated for hypertrophic scars, 20 for depressed scars,
and four for burn scars. Nine of 12 hypertrophic scars, 17 of 20 depressed scars, and
two of four burn scars were improved more than 50%.
PULSED DYE LASER
Flashlamp-pumped pulsed dye lasers have shown promise in both limiting ery-
thema in scars and attening them as well.39-41 This modality was also studied in 106
patients (171 anatomic sites) treated within 2 weeks after surgery where fast reso-
lution of scar stiffness and erythema and improvement in quality of scarring was
noted.42 However, a recent single-blind, randomized, controlled study in 20 pa-
tients with hypertrophic scars showed no improvements in hypertrophic scars fol-
lowing pulsed dye laser therapy.43
FREE ELECTRON LASER
The free electron laser is an infrared laser that is broadly tunable.This laser can de-
liver nonoverlapping pulses in a preformed pattern using a computer-assisted sur-
gical techniques system.44 Previous studies with the free electron laser have demon-
strated that wavelengths targeting vibrational modes of extracellular matrix protein
cause loss of structural integrity with minimal collateral damage.45,46 Edwards et
al45 reported that tissue ablation using the free electron laser set at 6.45 m resulted
in less thermal collateral injury than that generated by the CO2 laser. They also
stated that the free electron laser provides better scar reduction in vivo than CO2
resurfacing lasers and dermabrasion, the classic method for resurfacing scars.
CHEMICAL PEELS
Chemical peels can be used to atten scars in a manner similar to dermabrasion and
CO2 laser resurfacing. Chemical peels may be divided into super cial (for epider-

mal injury), medium depth (for super cial dermal injury to the papillary dermis),
and deep (for mid-dermal injury to the reticular dermis). Super cial peels can be
performed using alpha-hydroxy acids or 15% to 20% trichloroacetic acid. Agents
most frequently used to create a medium-depth peel include 35% trichloroacetic
acid, a combination of 35% tricarboxylic acid with 70% glycolic acid (Coleman
technique), and 35% tricarboxylic acid with Jessner’s solution (Monheit tech-
nique).47,48 The deep chemical peel agent includes 50% trichloroacetic acid and the
Baker-Gordon formula (3 ml SUP [standard unit of processing] liquid phenol, 2 ml
tap water, 8 drops liquid soap, and 3 drops cotton oil). Patients with a history of car-
diac, renal, or hepatic disease may not be candidates for phenol peels.
Skin preparation for any peel includes vigorous cleansing with an exfoliant to re-
move oils and debris.The use of acetone may provide more even penetration. For
medium depth or deep peels, patients may benefit from administration of mild
sedatives and antiin ammatory drugs to alleviate swelling and discomfort. Antivi-
ral and/or antibacterial agents are often used prophylactically for deeper peels.
As the depth of peel increases, the therapeutic effects increase, smoothing the skin
contour and generating more tightening of dermal collagen. Complications of
medium and deep chemical peels include prolonged erythema, infection, scarring,
and skin atrophy.49
SOFT TISSUE FILLERS
Atrophic depressed scars or pitlike scars such as those resulting from acne can some-
times be improved by the injection of soft tissue ller. One approach is to use a bi-
ologic material such as fat.The traditional approach to fat grafting involves the use
of a large piece of dermis and fat excised from another anatomic location. More re-
cently, micro-fat grafts have been popularized for the correction of subcutaneous
defects. W.P. Coleman50 has described in detail his harvesting and injection tech-
nique for lipotransfer. He aspirates fat from an area of fat excess and then uses a cen-
trifuge to separate fat cells from other components of the aspirate. He further breaks
up the aspirated fat by transferring it between two syringes attached through a
bi-Luer-Lok connector.51 The cells are then injected with small syringes into the
area to be treated.
AlloDerm (LifeCell Corp., Branchburg, NJ) is an acellular human dermal collagen
matrix that has found utility in a variety of clinical situations for soft tissue augmen-
tation. It can be placed within subcutaneous tissues to increase soft tissue bulk and
smooth irregular contours that can result from some types of scar.
Alternatively, a variety of injectable soft tissue llers are currently available commer-
cially. Bovine collagen, marketed as Zyderm and Zyplast (Inamed Aesthetics, Santa
Barbara, CA), is the injectable agent that has been available the longest. Bovine col-
lagen is detected as a foreign substance and is degraded by human collagenases and
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in ammatory cells over several months. Investigations in vivo have demonstrated
that bovine collagen is undetectable in the treated dermis 3 months after injection.
Therefore bovine collagen must be administered frequently to maintain its clinical
results, and it has been occasionally associated with allergic reactions.52,53
Cosmoderm and Cosmoplast (Inamed Aesthetics) are newer soft tissue llers that
include natural human collagen. These llers are considered to be less immuno-
genic, and it is speculated that they will degrade more slowly and last longer.
Other lling agents such as hyaluronic acid have also been recently approved for
human use. Hyaluronic acid is a naturally occurring polysaccharide found in inter-
cellular matrix that serves a primary role in the hydration, lubrication, and stabiliza-
tion of connective tissue. It has been approved for the treatment of facial rhytids.
Olenius54 evaluated 285 facial rhytids treated with hyaluronic acid and found that the
degree of correction or aesthetic improvement as rated by the physicians declined
from 98% at 2 weeks to 82% at 3 months, 69% at 6 months, and 66% at 1 year. Side
effects were infrequent and self-limited. It would be expected that improvement in
scar contours created by hyaluronic acid injections would last for similar periods.
ABNORMAL SCARRING CONDITIONS
KELOIDS AND HYPERTROPHIC SCARS
Hypertrophic scars and keloids develop exclusively in humans. They occur with
equal frequency in males and females and occur most commonly in younger peo-
ple, particularly in the second decade of life. They are differentiated by their gross
appearance. Hypertrophic scars are con ned to the area of injury, whereas keloids
proliferate beyond the boundaries of the original scar.141
Both keloids and hypertrophic scars cause itching, tenderness, and pain and fre-
quently recur after excision. The cause of both keloids and hypertrophic scars is
unknown, although both are associated with a prolonged in ammatory response
and increased extracellular matrix production.55-58
The anterior chest, shoulders, upper arms, and jawline have a predilection to abnor-
mal scarring. The increased incidence of abnormal scarring in these locations has
been attributed to increased skin tension in these areas.The eyelids, genitalia, palms,
soles, and mucous membranes are not commonly affected.59-63
There are some differences between the growth characteristics of keloids and hy-
pertrophic scars. Keloids may not appear immediately after injury. Although they
are generally evident within 3 months, they can rarely develop years after the orig-
inal injury.They almost never spontaneously recede. In contrast, hypertrophic scars
generally appear within 4 weeks of injury and often regress over time.64 Keloids pri-
marily occur in dark-pigmented individuals who are predisposed toward them.56,64-66

MANAGING ABNORMAL SCARRING
It can never be stated with assurance whether an abnormal scar will develop in a
speci c clinical environment. One can identify wounds and individuals that have a
greater likelihood of abnormal scarring, but nothing is 100% predictive. Similarly,
no one can guarantee that any treatment regimen will prevent recurrence.
Although no treatment is uniformly ef cacious, a variety of treatment options are
available. Some are more amenable to hypertrophic burn scars or linear incisions,
whereas others are more useful for keloids. Generally, less-invasive modalities are
preferred if they can produce the desired degree of improvement. Any treatment
regimen, including surgery or scar ablation, harbors the risk of exacerbating the
abnormal scarring.The risks and bene ts of all options available must be considered
when developing a treatment plan for a patient with abnormal scarring.
SILICONE SHEETING
The application of topical silicone gel sheeting has been used to either limit the de-
velopment of abnormal scars or treat them once they have occurred. The treat-
ment costs little and morbidity is low, so it is a good rst-line treatment for the
prevention or treatment of abnormal scars.
Several controlled trials have demonstrated the ef cacy of silicone gel sheeting for
managing hypertrophic scars and keloids.67 Ahn et al68,69 studied the effects of a sil-
icone gel bandage worn for at least 12 hours daily on the resolution of hyper-
trophic burn scars. They reported increased scar elasticity and diminished volume
scar after 1 and 2 months of treatment as compared with controls. Several authors
have treated a series of patients with abnormal scars with either silicone sheeting or
silicone gel– lled cushion and showed that in the majority of patients scar volume
was reduced.70-72 Agarwal et al67 performed punch grafting in 15 patients with vit-
iligo, using punches varying in diameter from 2 to 3 mm and used silicone gel
sheets as a postoperative dressing. Two months after biopsy, no cobblestoning or
other untoward effects were evident. The authors cited other advantages of the
sheeting, such as providing a sterile atmosphere for the grafts, facilitating periodic
observation because of their transparency, and easy removal at follow-up.
The mode of action of silicone materials is still unknown. It has been demonstrated
that their therapeutic effect is not caused by pressure, a difference in oxygen tension,
or temperature.73,74 It may be the occlusive nature of the material itself, which in-
creases the level of hydration of the skin.73,75 Hydration has been proven to mod-
ulate the activity of keratinocytes on broblasts.76,77 Keratinocytes in a moist milieu
down-regulate collagen and glycosaminoglycan synthesis by broblasts.75,78 It has
been recommended that the silicone material be worn 24 hours a day for at least
3 months to prevent rebound hypertrophy.79
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PRESSURE THERAPY
Pressure therapy has been used to manage hypertrophic scars and keloids since the
1970s. It is commonly used to limit the development of hypertrophic burn scars.80-85
It is felt that the pressure exerted should be at least 24 mm Hg to exceed the inher-
ent capillary pressure.86,87 The pressure is believed to cause ischemia, which de-
creases tissue metabolism and increases collagenase activity within the wound.79
Maintaining this pressure for months to 2 years has been shown clinically to resolve
hypertrophic scars permanently.87-89
It is generally recommended that pressure garments be worn 18 to 24 hours a day
for at least 4 to 6 months59,88,90-92 to prevent rebound hypertrophy after burn in-
jury.88 Like silicone sheeting, pressure therapy has limited morbidity and is a good
rst line treatment for abnormal scars. Pressure therapy and silicone sheeting can
also be used together.
A 60% to 85% reduction in burn scar hypertrophy has been reported with pressure
garments, though de nitive ef cacy has never been demonstrated in a randomized
prospective trial.93,94 In one of the few objective studies that has been performed,
Chang et al95 prospectively assigned patients in a random fashion to receive either
pressure garment therapy or no pressure garment therapy after burn injury; 122
consecutive patients were enrolled in the study. No significant differences were
found between the two groups when time to wound maturation was compared.
Pressure has also been used as an adjunctive modality to surgery in the treatment of
keloids and established hypertrophic scars. Pressure-generating earrings are partic-
ularly useful in treating keloids of the earlobe after surgery. Surgery followed by
pressure treatment has produced success rates of up to 90% to 100%.93,96-99
CORTICOSTEROID INJECTIONS
There is a broad consensus that injected triamcinolone is frequently ef cacious in
limiting the rmness and prominence of hypertrophic scars and keloids.26,80,90,100-104
The mechanism of action is not entirely known, although treatment with intrale-
sional steroid agents may increase local collagenase levels and diminish collagen
synthesis. Reported response rates vary from 50% to 100%, with recurrence rates of
9% to 50%.79 Although more invasive than silicone sheeting, this method can still
be employed in the outpatient clinic and has little chance of contributing to scar
worsening. For already established abnormal scars and scars which are not amenable
or responsive to treatment with pressure and silicone sheeting, corticosteroid injec-
tions can be useful.
Although a variety of steroids have been applied topically or intralesionally injected
for abnormal scars, triamcinolone acetate is probably the most effective and is most
commonly used.105,106 Up to 3 ml of 40 mg/ml triamcinolone acetate is injected at

one time.Treatments are spaced at 6-week intervals to minimize the chance of sys-
temic steroid effects. Two or three injections are usually suf cient, although occa-
sionally injections continue for 6 months or more.105,106 Complications of long-
term use can include tissue atrophy, depigmentation, and telangiectasia.
Various mechanisms of action for corticosteroid injection on scar resolution have
been postulated. Steroids affect almost all aspects of the healing process, but when
injected into abnormal scars, the primary effect is most likely related to an alteration
in the balance between collagen synthesis and breakdown by metallopro-
teinases.79,91,107-112
Injections may be used alone or as adjuncts to other therapies such as surgery.105
Tang113 showed promising results with a protocol consisting of surgical excision
combined with steroid injections intraoperatively, weekly postoperatively for 2 to
5 weeks and then monthly for another 3 to 6 months.
INTERFERON-ALPHA2B
Intralesional interferon-alpha2b (IFN-alpha2b) has been used more recently as a
treatment modality for keloids and hypertrophic scars. Like steroids, it can be used
alone or as an adjunct to surgical treatment. Interferon-alpha2b has been shown to
reduce serum TGF-beta concentration, and this may one of the primary actions of
interferon-alpha2b on scar remodeling.114
Intralesional interferon-alpha2b alone has been demonstrated to produce a reliable
reduction in keloid area with a recurrence rate of 8% to 18.7%.96,115 Tredget et al114
demonstrated that IFN-alpha2b injections three times weekly created a greater de-
gree of improvement in hypertrophic scars than seen in a control group.
Berman and Flores116 used IFN-alpha2b in an adjuvant setting for keloids and reported
that in lesions excised without postoperative injections, 51.1% recurred, while
18.7% of IFN-alpha2b–treated lesions recurred (p
0.025).They concluded that
injection of IFN-alpha2b offers a therapeutic advantage over keloid excision alone.
OTHER INTRALESIONAL AGENTS
Interferon-gamma has also been used as an intralesional agent in the treatment of
keloids and hypertrophic scars. Granstein et al117 reported that intralesional inter-
feron-gamma produced a mean reduction of 30.4% in scar volume versus 1.1% at
the control site. Larrabee et al118 demonstrated 50% reduction in 5 of 10 treated
scars after 10 weeks of intralesional interferon-gamma (IFN-gamma) injections.
Purported mechanisms of scar resolution with intralesional IFN-gamma include a
diminished quantity of thickened collagen bundles in the dermis, a reduced amount
of active broblasts, and an increased number of in ammatory cells.117
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Intralesional 5- uorouracil (5-FU) has been used successfully as monotherapy or in
combination with intralesional corticosteroids to treat hypertrophic scars and
keloids. Fitzpatrick119 reported success with a regimen that included one to three
injections of 5-FU per week; this was continued until the scars began to resolve.
The frequency of injections was then gradually diminished (weekly to monthly).
The combination of 5-FU and Kenalog was felt to be more effective and less
painful. 5-FU injections in combination with pulsed dye laser treatments were
deemed most effective.
Gupta and Kalra120 tested 5-FU injections on 24 patients with keloids of 6 cm or
less. One third of these patients showed more than 75% attening of the keloid.
Overall, about half of the patients showed more than 50% attening of the treated
keloid. Side effects included pain and hyperpigmentation in all patients tested.
Intralesional bleomycin injections have also proved effective for managing hyper-
trophic scars.121,122 A small pilot study by España et al123 in 13 patients showed com-
plete or signi cant attening (more than 90%) in 12 of 13 hypertrophic scars and
keloids after administration of bleomycin using a multiple-puncture method on
the skin surface. The authors suggested that further larger studies are needed to
con rm these ndings.
Intralesional verapamil has also been used, both independently and as an adjunct to
surgical treatment for keloids and hypertrophic scars. Lawrence124 administered in-
tralesional verapamil (2.5 mg/ml) 7 to 14 days after keloid removal and again, when
possible, approximately 1 month after removal. Patients were instructed to wear
pressure earrings essentially continuously for a minimum of 6 months after exci-
sion. Twenty-two keloids (55%) were cured by this modality, with a minimum
follow-up of 6 months.
TOPICAL AGENTS
Imiquimod 5% cream is currently approved for treatment of genital and perianal
warts, and it has also been used adjunctively in the treatment of keloids. It activates
natural killer cells, macrophages, and Langerhans cells and induces the local synthe-
sis and release of cytokines, including IFN-alpha2b, IFN-gamma, TNF-alpha, and
interleukins-1, -6, -8, and -12, when topically applied.125 There is a dose-dependent
inhibition of human broblast collagen production by IFN-alpha and IFN-gamma.126
Kaufman and Berman127 examined the effects of imiquimod 5% cream after surgi-
cal excision of 13 keloids from 12 adult patients. Imiquimod 5% cream was ap-
plied nightly, beginning the day of surgery and continuing for 8 weeks. At 24 weeks
after surgery, no recurrence of keloid growth was noted among any of the patients
who completed the study. Local skin reactions included pruritus and infection,
though no systemic effects were noted.

This patient underwent facial rejuvenation with an extended SMAS technique.
The 6-month postoperative result demonstrates the effect of excessive tension at the
earlobe, probably as a result of overexuberant skin excision. The area of hyper-
trophic scarring is outlined.
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Clark128 randomized 30 patients after keloid excision either to receive an IFN-
alpha2b injection the day of surgery and again 1 week later, or to apply imiquimod
5% cream to the surgical wound daily for 8 weeks. After 6 months, only one recur-
rence was reported in each group.
SURGERY FOR ABNORMAL SCARS
If silicone gel sheeting, pressure garments, and intralesional modalities are not suc-
cessful, or if the abnormal scar is extensive enough to make a complete response to
less-invasive treatment unlikely, surgical excision may be appropriate. Surgical ex-
cision alone results in elimination of approximately one third of keloids.105 Surgery
alone is more likely to be successful in circumstances in which abnormal scarring
developed after prolonged in ammation or extensive trauma. The healing envi-
ronment after a revision procedure would be quite different, and improved results
might reasonably be anticipated.
It is important to incorporate the basic surgical principles just discussed for any
surgical procedure to revise abnormal scars. Minimizing the use of permanent or
slowly dissolving sutures is recommended, because they may promote prolonged in-
ammation and increased scar production.

134
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At 3 months her scar is less visible.There is no evidence of hypertrophic scar recur-
rence.The line of closure is also less visible.
The operative plan involved excision of the hypertrophic scar and the recruitment
of skin rotated into the postauricular sulcus. In this manner the dog-ear can be
chased into an area of concealment. She is shown immediately after revision sur-
gery. Permanent skin sutures and minimal deep sutures were placed to avoid stim-
ulation of in ammation.

Some surgeons have promoted the use of intramarginal keloid excisions, where a
rim of keloid is left to stent the wound and potentially limit the stimulus for recur-
rent keloid formation. The ef cacy of this approach has not been substantiated.
Grafting of the excised area, sometimes using dermal and epidermal elements re-
moved from the excised keloid, has also been suggested as a method of closing a
wound resulting from keloid excision. Such grafts limit tension on the closed
wound and eliminate the need for creating an additional wound in a donor area.
In areas where tension is felt to be a contributing factor to abnormal scar development,
techniques such as the Z-plasty can also limit the likelihood of recurrence. However,
the irregular scar created by this technique may not be desirable in some locations.
An alternative approach to the Z-plasty is to use a series of small wave
incisions approximately 1 cm in length.These small wave incisions com-
bine to form a smooth wave shape, which approximates a straight line
after closure.Tension in the wound is reduced, and the result appears to
be an inconspicuous linear scar.129
OTHER ABLATIVE MODALITIES
Cryosurgery
Cryosurgery as a monotherapy regimen for treating hypertrophic scars and keloids
rst evolved in 1982.130 The extremely low temperatures generated by the cryo-
probe cause vascular damage and blood stasis within the keloid tissue that leads to
cell anoxia and death. Hoffmann et al demonstrated complete destruction of the
vasculature in the center of a cryosurgically treated area with a gradual transition to
normal vascular patency as one moved radially outward from the primary treat-
ment site.131 Shepherd et al130 demonstrated that a solitary cryosurgical session for
keloids achieved 80% improvement and a recurrence rate of 33%. Repeated sur-
face/spray cryosurgical sessions have also been demonstrated to produce a bene -
cial effect on hypertrophic scars and keloids (between 68% and 81% remission),
with almost no recurrence (2%).132,133 More recent studies report cryotherapy results
in keloid attening in 51% to 74% of patients after two or more sessions.134-136
Limitations in cryotherapy include the delay of several weeks required for postop-
erative healing and a side effect of permanent hypopigmentation. Other possible
side effects include hyperpigmentation, skin atrophy, and pain.137 Because only a
portion of the scar is eliminated, results are often less than ideal.
Lasers
Lasers of various types have been used to treat keloids and hypertrophic scars.
Purely ablative lasers such as the CO2 lasers generally produce success rates similar
to surgery alone.
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More-selective lasers, such as the YAG laser which targets blood vessels, have also
been used. In a recent study of 17 patients with keloids, nearly 60% of keloids were
attened following one session of YAG laser treatment. These patients remained
free of keloid scarring at 18-month to 5-year follow-up.138 The remaining seven pa-
tients required further laser treatment and intralesional corticosteroids to atten
the keloids completely. Recurrence of keloids occurred in three patients who re-
sponded to further laser treatment.
Improvements in appearance of hypertrophic scars and keloids have been noted in
57% to 83% of cases treated with the pulsed dye laser.139 Further improvements
were noted when used in combination with intralesional corticosteroids.139 A re-
cent pilot study has reaf rmed that laser treatment in combination with intrale-
sional corticosteroids is effective in eliminating previously resistant keloids.140
Radiotherapy
Radiotherapy has been used both as a primary treatment for keloids and hyper-
trophic scars and as an adjunctive modality in combination with surgical excision.
Response to radiotherapy alone is 10% to 94%, with a keloid recurrence rate of
50% to 100%. Best results have been achieved with 1500 to 2000 rads over ve or
six sessions in the early postoperative period.142,143 There have been mixed results
from radiotherapy after surgical excision of keloids, with signi cant objective re-
sponse rates reported in 25% to 100% of patients.144,145
Sclafani et al145 demonstrated improved results in keloid treatment with surgery
and adjuvant radiotherapy compared with surgery and corticosteroid injections
(12.5% versus 33% relapse at 12 months after treatment) in a prospective random-
ized trial.This difference did not reach statistical signi cance, however.
Ragoowansi et al146 reviewed 6741 cases of keloids treated adjunctively with radio-
therapy after surgical excision, including 4263 keloids in articles published from
1961 onward. Reported recurrence rates at 1 year or more vary from 53% to 2%.
These authors found only five cases of possible radiation-induced cancers after
keloid treatment despite the large number of patients treated.The crude risk from
the published data accessed is at most 1 in 1348.
TIMING OF SCAR REVISION
Ideally, scar revisions should be delayed for at least 6 months after a scar is created
to allow the normal healing process to approach completion.This interval provides
reasonable assurance that any unfavorable characteristic of the scar is not simply
related to incomplete healing. With time, many problems spontaneously resolve,
especially excessive scar erythema and prominence. Allowing scars to mature before

considering revision allows the tissues to soften and become more pliable. These
more natural tissue characteristics allow more precise surgical manipulations dur-
ing any revision procedure.
Some interventions are probably best carried out before a scar is fully mature. If a
scar is becoming hypertrophic, the progression of the process may be limited by the
application of pressure or topical silicone or intralesional injections with steroids or
other agents. Some promote dermabrasion to relatively immature scars to promote
more uniform healing of the scar surface.
Some scar problems will clearly not improve with time. Widened, atrophic scars
will not become narrower or atter, no matter what the time interval. Such prob-
lems may be addressed whenever the nature of the surrounding tissues allows it.
CONCLUSION
Complications related to scarring can result from almost any surgical procedure.
When faced with an unattractive or dysfunctional scar, one must first diagnose what
the problem is and then develop a hypothesis to explain why the problem might
have developed. An assessment must then be made as to whether the problem is
amenable to correction, and, if so, a decision must be made regarding which of the
many treatment options available for scar revision is most appropriate for the spe-
ci c clinical situation.
Although there are many therapeutic modalities currently available, the future may
hold newer and better techniques for modifying scars. Speci c agents that directly
affect cellular processes involved in healing may allow us to favorably in uence scar
production. These may include cytokines or antibodies that speci cally limit the
function of certain cytokines.Tissue engineering and expanded knowledge of ge-
netic modulators of tissue production may allow us to eventually stimulate tissue re-
generation instead of scar production. Such techniques could revolutionize wound
and scar management.
References—With Key Annotated References
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84. Nedelec B, Ghahary A, Scott P, et al. Control of wound contraction: Basic and clinical fea-
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85. Rayner K. The use of pressure therapy to treat hypertrophic scarring. J Wound Care 9:151-
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86. Sawada Y. Alterations in pressure under elastic bandages:Experimental and clinical evaluation.
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87. Kischer CW, Shetlar MR, Shetlar CL. Alteration of hypertrophic scars induced by mechan-
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88. Page RE, Robertson GA, Pettigrew NM. Microcirculation in hypertrophic burn scars. Burns
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89. Clark JA, Cheng JC, Leung KS, et al. Mechanical characterisation of human postburn hyper-
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90. Murray JC. Scars and keloids. Dermatol Clin 11:697-708, 1993.
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95. Chang P, Laubenthal KN, Lewis RW II, et al. Prospective, randomized study of the ef cacy
of pressure garment therapy in patients with burns. J Burn Care Rehabil 16:473-475, 1995.
96. Berman B, Bieley HC. Adjunct therapies to surgical management of keloids. Dermatol Surg
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97. Brent B.The role of pressure therapy in management of earlobe keloids: Preliminary report
of a controlled study. Ann Plast Surg 1:579-581, 1978.
98. Mercer DM, Studd DM.“Oyster splints”: A new compression device for the treatment of
keloid scars of the ear. Br J Plast Surg 36:75-78, 1983.
99. Pierce HE. Postsurgical acrylic ear splints for keloids. J Dermatol Surg Oncol 12:583-585,
1986.
100. Urioste S, Arndt KA, Dover JS. Keloids and hypertrophic scars:Review and treatment strate-
gies. Semin Cutan Med Surg 18:159-171, 1999.
101. Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: A comprehensive re-
view. Plast Reconstr Surg 84:827-837, 1989.
102. Alster TS,West TB.Treatment of scars: A review. Ann Plast Surg 39:418-432, 1997.
103. Murray JC. Keloids and hypertrophic scars. Clin Dermatol 12:27-37, 1994.
104. Grif th BH, Monroe CW, McKinney P. A follow-up study on the treatment of keloids with
triamcinolone acetonide. Plast Reconstr Surg 46:145-150, 1970.
105. Lawrence WT. In search of the optimal treatment of keloids: Report of a series and a review
of the literature. Ann Plast Surg 27:164-178, 1991.
106. Boyadjiev C, Popchristova E, Mazgalova J. Histomorphologic changes in keloids treated with
Kenacort. J Trauma 38:299-302, 1995.
107. Alaish SM,Yager DR, Diegelmann RF, et al. Hyaluronic acid metabolism in keloid broblasts.
J Pediatr Surg 30:949-952, 1995.
108. McCoy BJ, Diegelmann RF, Cohen IK. In vitro inhibition of cell growth, collagen synthe-
sis, and prolyl hydroxylase activity by triamcinolone acetonide. Proc Soc Exp Biol Med
163:216-222, 1980.
109. Kauh YC, Rouda S, Mondragon G, et al. Major suppression of pro-alphal (I) type I collagen
gene expression in the dermis after keloid excision and immediate intrawound injection of
triamcinolone acetonide. J Am Acad Dermatol 37:586-589, 1997.
110. Lavker RM, Schechter NM. Cutaneous mast cell depletion results from topical cortico-
steroid usage. J Immunol 135:2368-2373, 1985.
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111. Gadson PF, Russell JD, Russell SB. Glucocorticoid receptors in human fibroblasts derived
from normal dermis and keloid tissue. J Biol Chem 259:11236-11241, 1984.
112. Krusche T, Worret WI. Mechanical properties of keloids in vivo during treatment with in-
tralesional triamcinolone acetonide. Arch Dermatol Res 287:289-293, 1995.
113. Tang YW. Intra- and postoperative steroid injections for keloids and hypertrophic scars. Br J
Plast Surg 45:371-373, 1992.
114. Tredget EE, Shankowsky HA, Pannu R, et al.Transforming growth factor-beta in thermally
injured patients with hypertrophic scars: Effects of interferon alpha-2b. Plast Reconstr Surg
102:1317-1328; discussion 1329-1330, 1998.
115. Berman B, Duncan MR. Short-term treatment in vivo with human interferon alpha-2b re-
sults in a selective and persistent normalization of keloidal broblast collagen, glycosamino-
glycan, and collagenase production in vitro. J Am Acad Dermatol 21:694-702, 1989.
116. Berman B, Flores F. Recurrence rates of excised keloids treated with postoperative triamcin-
olone acetonide injections of interferon alfa-2b injections. J Am Acad. Dermatol 37:755-
757, 1997.
117. Granstein RD, Rook A, Flotte TJ, et al. Controlled trial of intralesional recombinant inter-
feron-gamma in the treatment of keloidal scarring. Arch Dermatol 126:1295-1302, 1990.
118. Larrabee WF Jr, East CA, Jaffe HS, et al. Intralesional interferon gamma treatment for keloids
and hypertrophic scars. Arch Otolaryngol Head Neck Surg 116:1159-1162, 1990.
119. Fitzpatrick RE. Treatment of in amed hypertrophic scars using intralesional 5-FU. Derma-
tol Surg 5:224-232, 1999.
120. Gupta S, Kalra A. Efficacy and safety of intralesional 5- fluorouracil in the treatment of
keloids. Dermatology 204:130-132, 2002.
121. Bodokh I, Brun P. Traitement des chéloïdes par in ltrations de Bléomycine. Ann Dermatol
Venereol 123:791-794, 1996.
122. Larouy JC.Traitement des chéloïdes:Trois méthodes. Nouv Dermatol 19:295, 2000.
123. España A, Solano T, Quintanilla E. Bleomycin in the treatment of keloids and hypertrophic
scars by multiple needle punctures. Dermatol Surg 27:23-27, 2001.
124. Lawrence WT. Treatment of earlobe keloids with surgery plus adjuvant intralesional verap-
amil and pressure earrings. Ann Plast Surg 37:167-169, 1996.
125. Berman B,Villa A. Imiquimod 5% cream for keloid management. Dermatol Surg 29:1050-
1051, 2003.
126. Jimenez SA, Freundlich B, Rosenbloom J. Selective inhibition of diploid broblast collagen
synthesis by interferons. J Clin Invest 74:1112-1116, 1984.
127. Kaufman J, Berman B. Pilot study of the effect of postoperative imiquimod 5% cream on
the recurrence rate of excised keloids. J Am Acad Dermatol 47(4 Suppl):S209-S211, 2002.
128. Clark J. Imiquimod vs. interferon:Cream matches injection in terms of eliminating keloid re-
currence while showing no adverse events. Dermatol Times Dec 15-16, 2002.
129. Hyakusoku H, Ogawa R. The small-wave incision for long keloids. Plast Reconstr Surg
111:964-965, 2003.
130. Shepherd JP, Dawber RP. The response of keloid scars to cryosurgery. Plast Reconstr Surg
70:677-682, 1982.
131. Hoffmann NE, Bischof JC. Cryosurgery of normal and tumor tissue in the dorsal skin ap
chamber: II. Injury response. J Biomech Eng 123:310-316, 2001.
132. Zouboulis CC, Blume U, Buttner P, et al. Outcomes of cryosurgery in keloids and hyper-
trophic scars: A prospective consecutive trial of case series. Arch Dermatol 129:1146-1151,
1993.
133. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol
Surg Oncol 19:529-534, 1993.
134. Layton AM,Yip J, Cunliffe WJ. A comparison on intralesional triamcinolone and cryosurgery
in the treatment of acne keloids. Br J Dermatol 130:498-501, 1994.

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135. Ciampo E, Iurassich S. Liquid nitrogen cryosurgery in the treatment of acne lesions. Ann Ital
Dermatol Clin Sper 51:67, 1997.
136. Ernst K, Hundeiker M. [Results of cryosurgery in 394 patients with hypertrophic scars and
keloids] Hautarzt 46:462-466, 1995.
137. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol
Surg Oncol 19:529-534, 1993.
138. Kumar K, Kapoor BS, Rai P, et al. In-situ irradiation of keloid scars with Nd:YAG laser. J
Wound Care 9:213-215, 2000.
139. Goldman M, Fitzpatrick RE. Laser treatment of scars. Dermatol Surg 21:685-687, 1995.
140. Connell PG, Harland CC.Treatment of keloid scars with pulsed dye lasers and intralesional
steroid. J Cutan Laser Ther 2:147-150, 2000.
141. Cosman B, Crikelair GF, Ju DM, et al.The surgical treatment of keloids. Plast Reconstr Surg
27:335, 1961.
142. Brown LA Jr, Pierce HE. Keloids: Scar revision. J Dermatol Surg Oncol 12:51-56, 1986.
143. Levy DS, Salter MM, Roth RE. Postoperative irradiation in the prevention of keloids. Am J
Roentgenol 127:509-510, 1976.
144. Edsmyr F, Larson LG, Onyango J, et al. Radiotherapy in the treatment of keloids in East
Africa. East Afr Med J 50:457-461, 1973.
145. Sclafani AP, Gordon L, Chadha M, et al. Prevention of earlobe keloid recurrence with post-
operative corticosteroid injections versus radiation therapy: A randomised, prospective study
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146. Ragoowansi R,Cornes PGS,Moss AL, et al.Treatment of keloids by surgical excision and im-
mediate postoperative single-fraction radiotherapy. Plast Reconstr Surg 111:1853-1859, 2003.
This is an impressive review article covering virtually all reported cases of radiotherapy-directed scar
revision in the last 40 years as well as a historical review of the eld.

144
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SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
1. Which of the following statements is true of keloids?
a. They are seldom present on the anterior chest, shoulders, upper arms, and
jaw
b. They can frequently spontaneously recede
c. They tend to occur in lighter-skinned individuals
d. Unlike hypertrophic scars, keloids do not cause itchiness, redness, or pain
e. The palms, soles, and mucous membranes are not typically affected
2. Which of the following is not true of the Z-plasty?
a. It is suitable for revision of ATL scars of eyelids, lips, nasolabial folds, and
nonfacial areas that limit tissue mobility
b. The central limb of the Z-plasty should always fall over the scar
c. The aps should be oriented so that after transposition, they are oriented
close to RSTLs
d. The length of all limbs must be nearly equal
e. The original central limb increases in length by a factor of 2
3. Which of the following is important to obtaining a more favorable scar?
a. Gentle handling of tissues to minimally traumatize structures in the revi-
sion
b. Tension-free wound closure to minimize stress on healing tissues
c. Incisions are made perpendicular to the skin edge to allow precise reap-
proximation
d. Incisions are ideally oriented within the RSTLs to the degree possible
e. All of the above
4. All of the following are true of chemical peels except:
a. Chemical peels may be divided into superficial (epidermal injury),
medium-depth (superficial dermal injury to the papillary dermis), and
deep (mid-dermal injury to the reticular dermis)
b. Super cial peels can be performed using alpha hydroxy acids or 15% to
20% trichloroacetic acid
c. Antiviral and/or antibacterial agents are never used prophylactically for
deeper peels
d. Agents most frequently used to create a medium-depth peel include 35%
trichloroacetic acid, a combination of 35% tricarboxylic acid with 70%
glycolic acid (Coleman technique), and 35% tricarboxylic acid with Jess-
ner’s solution (Monheit technique)
e. The deep chemical peel agent includes 50% trichloroacetic acid and the
Baker-Gordon formula (3 ml SUP liquid phenol, 2 ml tap water, 8 drops
liquid soap, and 3 drops cotton oil)
R EVIEW QUESTIONS

145
Chapter 6
Scars and Scar Revision
5. All of the following are true of wound healing except:
a. In ammatory mediators such as histamine, prostacyclins and leukotrienes
contribute to vasoconstriction
b. Prolonged in ammation can result in an excess of in ammatory mediators
and cytokines in the wound environment
c. After the in ammatory reaction to injury begins to diminish, keratino-
cytes and mesenchymal cells begin to actively migrate into the wound
environment and proliferate
d. In addition to active collagen synthesis, appropriate metalloproteinase
function is required to modulate the quantity and alignment of scar in a
wound
e. Protein de ciency results in impairments in capillary formation, broblast
proliferation, and collagen synthesis

(Trang không có chữ)

147
Reoperation for Donor Site
Complications
James C. Grotting and Grady B. Core
C ha pter 7
Reoperative Problems
Scarring
Impaired function
Contour deformities
Pain
Hernia
Aesthetic de ciencies
I think everyone should experience defeat
at least one time during their career.
You learn from it.
Lou Holtz
Donor site complications have been a relatively unreported area in comparison
with other problems in reconstructive surgery. This is unfortunate, because donor
site morbidity should be optimally minimized and the potential complications
should be well known to all who undertake reconstructive procedures. Donor site
problems can be divided into those that involve nonvascularized tissue and those in-
volving vascularized tissue. When such complications occur, reoperative measures
are frequently required.

148
PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
NONVASCULARIZED GRAFT COMPLICATIONS
SKIN
The most common complication of split-thickness skin grafts at the donor site that
may require reoperation is deep partial-thickness injury or full-thickness injury re-
sulting from either overzealous harvesting or secondary infection. If the donor site
is small and the wound is clean, it can simply be excised and closed primarily;how-
ever, this is usually not the case. It is best to wait 2 to 4 weeks before undertaking
reoperation, because many of these defects heal with time, with skin regenerating
from residual skin appendages. Care should be taken to use a nonadherent dress-
ing during the healing period so that regenerating epithelium is not destroyed dur-
ing dressing changes. If the area is not healing well within 2 weeks or is obviously
a full-thickness injury, the wound should be closed with a thin skin graft from an-
other area or with local aps.
Another donor site complication associated with split-thickness or full-thickness
skin grafting that may require reoperative surgery is hypertrophic scarring or keloid
formation. In a patient with no previous history of scarring problems, the wound
can be excised and reclosed with local injection of triamcinolone around the
wound edges. Controversy exists as to whether intralesional versus extralesional
excision of keloids reduces their recurrence rate. Although no clearly established
bene t of one method over the other has been proved, there is theoretical support
for intralesional excision.1
Otherwise, in high-risk patients, nonoperative measures such as steroid injections
and topical silicone sheeting2 should be employed initially. In some cases adjunctive
irradiation may be useful. Excision and radiation have been shown to reduce the re-
currence rate to approximately 2% with no evidence of carcinogenesis over many
years.3
BONE
Although bone grafts may be harvested from a variety of sites, the most common
donor sites are the ilium, the outer table of the calvarium, and rib. Risks of infec-
tion or bleeding that may require secondary drainage are common to all bone
donor sites. However, each site has speci c risks that may call for reoperative inter-
vention.
Cranium
The major risk to the cranial bone donor site is intracranial bleeding. Fortunately,
this event is rare, but the consequences are serious. Neurosurgical consultation and
intervention should be obtained immediately. Other secondary complications of
cranial bone harvesting are contour deformity and alopecia. The partial-thickness
calvarial defect can be lled with bone paste produced by mixing bone shavings
with blood. This paste can be smoothed into the defect to prevent a secondary
contour deformity. Bone wax application in the donor site should be minimized,

149
Chapter 7
Reoperation for Donor Site Complications
because this substance creates a physical barrier to the regeneration of the outer
table and can cause deformities to be persistent.4 Contour deformities anterior to
the hairline are caused by poor donor site selection and can be managed by re-
grafting the donor site from a more posterior site or by lling the defect with bone
dust or an alloplastic material such as methylmethacrylate or hydroxyapatite. Alope-
cia can be managed by excision and primary closure if the site is small. If a large area
is involved, tissue expansion or scalp aps may be required.
Rib
Rib graft harvesting may be complicated by a hemopneumothorax; in this case, a
tube thoracostomy would be indicated. However, if the wound is sealed and the
pneumothorax is small and not enlarging, simple aspiration may suf ce. Small pneu-
mothoraxes can resolve spontaneously, but serial chest radiographs should be ob-
tained to con rm resolution. In general, pneumothoraxes affecting less than 20% of
the lung eld with a sealed wound do not require tube thoracostomy.5
Ilium
Bone grafts of cancellous or cortical bone may be taken from the anterior or pos-
terior ilium.6 The anterior ilium is the more popular donor site. However, approx-
imately three times more cancellous bone can be obtained from the posterior ilium
than from the anterior ilium.7 Problems and complications associated with harvest-
ing a bone graft from the posterior ilium are pain, dif culty with ambulation, and
possible damage to the superior and medial cluneal nerves. Fortunately, the latter
problem is uncommon, as is damage to the sacroiliac joint and the sciatic nerve.6,7
The complications that these two donor sites share are pain, dif culty of ambula-
tion, blood loss, and hematoma formation. Patients who have undergone posterior
iliac harvesting may have dif culty climbing stairs because of the detachment of the
gluteus maximus muscle. Some very unusual complications have been reported in
association with the posterior iliac crest donor site, such as traumatic arteriovenous
stula and ureteral injury.8
The need for reoperative intervention for these two donor sites is rare. Drainage of
a hematoma is the most commonly indicated reoperative procedure associated with
the bone graft donor site.
Other unfavorable outcomes resulting from harvesting of iliac bone grafts include
abdominal herniation, vascular injuries, and fracture of the wing of the iliac bone.
Hematoma formation can be minimized with the use of micro brillar collagen
products such as Avitene.
CARTILAGE
The most common sites of cartilage graft harvesting are the septum, ear, and ribs.
Complications resulting from septal cartilage harvesting are usually caused by over-
harvesting. Loss of tip support, collapse of the nasal dorsum, and permanent septal

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perforation may require reoperation. These complications and their management
are addressed in Chapter 21. Fortunately, the harvesting of conchal cartilage is rarely
associated with complications. The most common problems are hematoma and
asymmetry, but hypertrophic scarring has occurred. Asymmetries must be evaluated
individually and treated accordingly.
Rib cartilage graft harvesting may be associated with the same complications as
noted for rib bone graft harvesting. Secondary intervention would be the same.
VEIN
Autogenous tissue for vascular grafts is usually supplied by the super cial veins of
the extremities such as the saphenous or cephalic veins. Secondary complications at
these donor sites that may require reoperation are seroma, hematoma, or secondary
infection, all of which may require incision and drainage. Occasionally, neuromas
can form at the incision site, which, if unresponsive to conservative measures, may
be an indication for reoperation (see Chapter 49). The saphenous nerve, which
courses in close proximity to the saphenous vein in the lower leg, is often injured
when this vein is harvested.
NERVE
Nerve grafts may be harvested from several different areas.The most common sites
are the sural region on the posterior lower extremity, the cervical region in the
neck, and the forearm. In addition to local wound complications, these nerve graft
donor sites share the risk of neuroma formation; this problem is most common in
the extremities. Secondary treatment of neuromas in the extremities initially in-
volves conservative measures such as observation and massage for desensitization.
Local injection of an ablative solution such as isopropyl alcohol has also been used,
but this approach is controversial and rarely offers a permanent cure.
Reoperative management consists of localization of the neuroma and, if possible, re-
pair of the nerve in continuity with its distal remnant. If this is not possible, second-
ary nerve grafting may help to resolve the neuroma. Otherwise, implantation of
the proximal nerve into adjacent muscle or bone has been described as a thera-
peutic measure.9,l0 Simply resecting the nerve more proximally has been successful
in some cases but is a second-line measure.Treatment of neuromas in the extrem-
ities is discussed in detail in Chapter 49.
FAT
Donor site complications for fat graft harvesting are quite rare. Usually fat grafts are
obtained through liposuction, but at times direct excision may be employed.11 Sec-
ondary complications requiring reoperation may consist of hematoma, seroma, and
secondary infection, which may call for incision and drainage. Occasionally, contour

defects may occur, which are an indication for reoperation using secondary liposuc-
tion or lipoinjection. However, these defects are very dif cult to correct and in
some cases may be permanent.
FASCIA AND TENDON
Nonvascularized fascial grafts are harvested primarily from the lateral thigh when
indicated for uses requiring structural support of the recipient site. Occasionally,
however, fascial grafts are also taken in the head and neck area for aesthetic purposes
such as rhinoplasty. These grafts are usually from the temporoparietal fascia. Be-
yond the grafts mentioned, nonvascularized fascial grafts are unusual.
Sources for tendon grafts include the palmaris longus muscle, plantaris muscle, and
extensor digitorum longus muscle.The super cialis tendon to the little nger from
an injured hand can also be used. Reoperative indications for these donor sites are
unusual outside routine local wound complications.
VASCULARIZED FLAPS
Although a variety of skin ap classi cations have evolved, none is ideal.The sim-
plest system classi es skin aps according to their blood supply:random cutaneous,
fasciocutaneous, and musculocutaneous.12 Regardless of the type of ap used, the
donor site morbidity created by raising the ap is usually minimal. All ap compli-
cations can be categorized as site speci c or non–site speci c; the latter includes
general wound complications.
R ANDOM CUTANEOUS FLAPS
The most common complaint concerning cutaneous aps is that the defect created
may be unsightly.To reduce the chances of an unusually unsightly donor site, every
effort is made to achieve primary closure. If this is not feasible, the surgeon should
consider local ap techniques that facilitate donor site closure, such as advance-
ment, rotation, or interpolation aps.12 If this is not possible, skin grafting must be
considered. Flaps such as the deltopectoral ap or the transverse back ap leave
large areas of exposed underlying muscle and fascia, which require skin grafting
for closure. If the patient requests aesthetic re nement of these donor sites, revisions
can be performed with tissue expansion techniques.13,14 Expansion can be per-
formed either before ap transfer or at a later date as a secondary procedure to
correct the donor site.14,15 Depending on the location of the defect, tissue expan-
sion may not always be feasible.The lower extremity, especially below the knee, has
been shown to be an area of high risk for complications with tissue expansion tech-
niques.16 Other methods for closure of large cutaneous defects include presuturing17
and more recently the use of a skin-stretching device.18 Both techniques attempt to
harness the viscoelastic properties of skin so that primary closure may be obtained
without resorting to skin grafting or tissue expansion.19 At present, only a few clin-
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ical cases have been reported, and thus the techniques are unproved. However, the
techniques deserve mention based on their theoretical potential and early reported
results.
Intraoperative expansion has also been advocated for the closure of large skin de-
fects. However, some investigators have demonstrated no bene t of this technique
over standard undermining techniques.20
The surgeon should be aware of situations in which primary closure of a ap donor
site by any method is not the best option. For example, for certain facial defects re-
sulting from Mohs’chemosurgery, delayed reconstruction or secondary healing may
be the best plan. In some cases the aesthetic results achieved with secondary heal-
ing may be superior to those possible with primary closure.21,22
FASCIAL AND FASCIOCUTANEOUS FLAPS
The most commonly used free fascial or free fasciocutaneous flaps are the flaps
from the radial forearm, scapula, lateral arm, and temporoparietal fascia. Manage-
ment of donor site deformities after fascial and fasciocutaneous ap harvest is sim-
ilar to that for skin aps. Primary closure of the donor site should be performed
whenever possible. However, if closure of the defect with local aps or skin graft-
ing is not possible, tissue expansion or stretching techniques can be used. In the
text that follows, we address some of the site-speci c problems that can occur with
these more common donor sites.
Radial Forearm Flap
The radial forearm donor site has been the source of the greatest volume of liter-
ature on donor site morbidity for virtually any type of ap.15,23-29 The reason is sim-
ple: morbidity is high.23-29 The incidence of delayed healing as the result of skin
graft failure has been reported to be as high as 50%.15,23 Skin graft failure usually re-
sults from the grafts not taking well over the exposed tendons in the forearm. In
cases for which direct closure with local aps is not feasible,23 the exor carpi ra-
dialis tendon that is exposed can be oversewn with neighboring muscle bers to
create a better bed for skin graft adherence.27 In addition, these tendons can be
covered with a pronator quadratus muscle flap on which the skin graft is then
placed.30,31 A reverse radial forearm fascial ap has been described in which the ra-
dial artery is spared and the deep fascia remains in the bed of the donor site, thus
making the donor site more easily skin grafted.32 Tissue expansion techniques for
donor site closure, using either preexpansion of the ap or late reconstruction with
expansion, have been used with good results, although the morbidity rate for tissue
expansion techniques in the upper extremity can be high.13,16
Other site-speci c problems that occur with the radial forearm ap donor site in-
clude persistent or intermittent swelling;stiffness of the hand, wrist, elbow, or shoul-

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der; reduced grip strength; reduced or abnormal sensation in all or part of the ra-
dial nerve distribution;cold intolerance;and fracture of the radius when the ap is
raised as an osteocutaneous ap.26,33
Reconstruction of the radial artery has been recommended in the past because of
concerns about vascular compromise.28 However, several large series in which the
radial forearm flap was transferred without radial artery reconstruction have
demonstrated no signi cant morbidity in this regard.23,34 In addition, a comparative
study of the operated arm versus the unoperated arm using noninvasive vascular
techniques revealed no statistically signi cant difference between the two sides, ex-
cept in early rewarming of the radial side of the hand after cold immersion at 1
minute.34 By 5 minutes the operated side matched the unoperated side in temper-
ature. Arterial reconstruction, therefore, should not be routinely performed but is
indicated if distal ischemia is noted intraoperatively. In addition, if the patient has an
underlying condition that predisposes to vascular compromise (for example, a va-
sospastic condition, or atherosclerosis), arterial reconstruction should be consid-
ered.
Scapular Flap
With the harvest of the scapular or parascapular ap, primary closure of the donor
site is possible in most cases. When primary closure is not obtainable, the alterna-
tive techniques already mentioned can be used. However, skin grafting is dif cult
in this area because of shoulder motion. For this reason primary closure is the rule,
if at all possible. Dehiscence should be managed with prompt reclosure unless the
wound is contaminated or infected. Closure by secondary intention can be
achieved with fair results if other techniques are not feasible.
This patient underwent transfer of a complex scapular osteomyocutaneous ap for
extensive facial reconstruction. Donor site healing was complicated by dehiscence;
the site was allowed to heal by secondary intention. Options for improvement in-
clude excision followed by deepithelialized advancement ap vest-over-pants clo-
sure and additional autologous fat injection.

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Lateral Arm Flap
The lateral arm ap has been well accepted by clinical surgeons because of its low
donor site morbidity and its favorable properties as a thin fasciocutaneous ap.35 The
need to reoperate because of donor site problems is rare.However,potentially serious
site-speci c problems include radial nerve injury and fracture of the humerus as a
result of overzealous osteotomy when harvesting an osteocutaneous ap.33
Temporoparietal Fascial Flap
The temporoparietal fascial ap donor site is the most ideal of all donor sites, be-
cause morbidity requiring reoperation is virtually nonexistent in this area. Reoper-
ation is usually only to address minor aesthetic concerns such as alopecia correction
or lling in the temporal fossa region with a Silastic or Medpor implant if the tem-
poralis muscle is harvested or injured.36,37
Lower Extremity Fasciocutaneous Flap
For fasciocutaneous aps in the lower extremity, as is true after the harvest of such
aps from other areas on the body, the primary donor site defect consists of an un-
sightly depression, usually requiring skin grafting for closure. Consequently, there
may be areas of exposed tendons where skin graft adherence is poor, thus resulting
in secondary defects that consist of chronic open wounds with exposed tendons.
Coverage of these tendons by oversewing local muscle tissue should be achieved if
at all possible. Tissue expansion techniques in the lower extremity, although feasi-
ble, have been fraught with high complication rates consisting of paresthesia or
numbness, lymphedema, cellulitis, and extrusion.17
W hen reoperation for fasciocutaneous donor site defects for aesthetic
purposes is considered, tissue expansion is still the best method cur-
rently available.
Site-speci c risk factors in this area are minimal, although one should always keep
in mind the location of the super cial peroneal nerve and thus avoid injuring it.
MUSCLE AND MUSCULOCUTANEOUS FLAPS
Complications of muscle and musculocutaneous aps that require reoperation can
also be categorized as those that are site specific and those that all sites have in
common: hematoma, seroma, wound infection, dehiscence, skin graft loss, and
necrotizing fasciitis.
Complication rates for musculocutaneous aps vary greatly. Frequently the compli-
cation is in the donor site. For the tensor fascia lata ap, the complication rate is ap-
proximately 19%.The overall complication rate for the latissimus dorsi ap is 31%.38
The inability to close a latissimus dorsi donor site has been treated with a “reverse”
latissimus dorsi musculocutaneous ap.39

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Complications associated with the harvesting of musculocutaneous aps are possi-
ble in any ap, no matter what the site, although some general wound complica-
tions are more common in speci c sites. For example, the most common compli-
cation of the latissimus dorsi donor site is seroma.38 Seromas should be aspirated if
large;otherwise, they can be treated with compression. Aspiration of seromas should
always be performed with sterile technique. After aspiration, compression should be
applied.
Brachial plexus injury has been associated with any surgery that requires arm ab-
duction.Therefore this complication is a potential problem with the latissimus dorsi
ap, scapular ap, gluteal ap, and TRAM ap, as recently reported.40 Reoperative
experience for this problem is limited, and improvement is most likely based on pa-
tience and physical therapy. Occasionally, persistent nerve compressions docu-
mented by electromyography and nerve conduction velocity testing may require
exploration and release. Avoidance of this problem is based on close attention to
position, pressure, and padding.
The “at risk” position for brachial plexus stretch injury is with the arm extended,
abducted, and externally rotated with the neck exed and rotated.
Attention to axillary pressure, no matter what procedure is being performed, is im-
portant. However, in our free TRAM ap series, in which upper extremity neu-
ropathy occurred in four of 117 cases, it was found that those patients with neu-
ropathy most likely had preexisting predisposing conditions.40 Therefore any patient
who is about to undergo extensive surgery in this region, whether for harvesting
the latissimus dorsi ap or insetting a free TRAM ap and who has a prior history
of peripheral nerve problems in the upper extremity should undergo preoperative
screening for subclinical peripheral nerve compression. This information must be
documented in the medical record.
Improper position creating
maximum stretch on brachial plexus

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Some morbidity is associated with loss of the muscle unit itself. Of course, the
function associated with that muscle is lost if the whole muscle is taken or dener-
vated. Fortunately, the redundant muscular system in the body allows the sacri ce
of these muscle units with remarkably little morbidity. However, with certain mus-
cle aps, particularly in elderly patients, this diminished function may be a source
of postoperative dif culty. For example, the trapezius muscle is a powerful stabilizer
of the medial scapula and shoulder joint. In rare instances, its sacri ce may be as-
sociated with shoulder dysfunction from this loss of support.
TRAM Flap
The most common causes for the need to reoperate a TRAM ap donor site are
skin necrosis of the abdominal ap, hematoma, seroma, wound infection, and dehis-
cence.38 Less common, but no less formidable, is abdominal wall hernia or eventra-
tion. Other rare indications include bowel obstruction and pelvic hematoma. Har-
trampf41 outlined criteria for patient selection to minimize these problems.
After TRAM flap breast reconstruction, this patient complained of intermittent
crampy abdominal pain with a weakness in the left lower quadrant of the abdom-
inal wall.

At the time of the exploratory operation, the patient was found to have not only
an abdominal wall hernia but also perforation of the small bowel, with Prolene su-
tures creating partial obstruction.
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Reoperation for Donor Site Complications
After bowel resection, primary anastomosis, and Gore-Tex patch repair of the ab-
domen, the patient recovered and has been well for 1 year without evidence of re-
currence.

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Management of donor site seromas or hematomas should be aggressive, with
prompt drainage as soon as the collection is identi ed. Seromas can be collapsed by
placing a suction drain or, if small, with intermittent syringe drainage and com-
pression. If detected early, hematomas should be reexplored and drained, and the
bleeding sites should be controlled.
The surgeon should be especially aware of the possibility of a “hid-
den” hematoma, which is characterized by a dropping hemoglobin level
and blood volume with no visible collection of blood in the operative
sites. A fullness in the groin or pain may be the only physical ndings.
If clinical and laboratory ndings indicate continuing blood loss, the pa-
tient should undergo reexploration to detect bleeding in the vicinity of
the deep inferior epigastric vessels.
Skin necrosis should always be managed conservatively if the wound is dry and
free of infection. The edge of the viable skin will demarcate, creating a blackened
eschar inferiorly that will eventually slough, leaving a bed of granulation tissue be-
neath. Early debridement of the nonviable skin is not advised if the skin is not in-
fected, since this may allow the remaining upper abdominal skin ap (which is un-
der tension) to retract, thus causing a much larger defect. Once the flap is well
adherent to the abdominal wall and the eschar has begun to separate (usually in 3
to 4 weeks), debridement may be initiated. Topical mafenide (Sulfamylon) cream
(applied to the eschar only) will penetrate the eschar and help to protect the
necrotic tissue from becoming infected.42-44 If at any time the wound begins to ap-
pear infected or “soupy,” debridement should be performed and all nonviable tis-
sue should be removed.
Once the wound is clean, it should be allowed to heal by secondary intention rather
than by skin grafting, because the contracture of the wound will help the defect to
shrink, and in many cases the eventual result will be satisfactory. Scar revisions on
small, healed, contracted wounds are much easier than on large skin-grafted areas.

The patient underwent giant prosthetic reinforcement of the visceral sac using Pro-
lene mesh. Six months after the repair, she shows no evidence of recurrence.
159
Chapter 7
Reoperation for Donor Site Complications
In this patient with Raynaud’s syndrome, problems with skin ap necrosis occurred
immediately postoperatively after bilateral free TRAM breast reconstruction. The
exposed mesh was removed, and the wound was allowed to heal by secondary in-
tention.

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After wound dehiscence exposed the underlying Gore-Tex prosthesis, this patient
required removal of the Gore-Tex patch, thus giving rise to abdominal wall weak-
ness and herniation. A hernia is noted in the right lower quadrant below the arcu-
ate line with eventration of the entire region because of attenuation of the fascia
and retraction of rectus abdominis muscle.
The entire area of weakness was excised, and repair was performed using a giant
prosthetic reinforcement of the visceral sac (see Chapter 44).

Six months postoperatively, the patient is without evidence of recurrence.
Necrosis of the umbilical stalk should be managed nonoperatively because it will
eventually slough.The resultant scar will in many cases serve as an acceptable um-
bilicus.
Reoperation for eventration or hernia should always be performed electively well
after the patient has recovered from the initial surgery if no acute problem has re-
sulted from the hernia. Most hernias will occur in the lower abdomen below the
arcuate line and result from the loss of anterior abdominal wall support.43-45 Most
commonly the fascial repair fails outright, the muscle has been harvested too low
or allowed to retract toward the pubis, or the edge of the internal oblique muscle
has not been secured in a two-layer fascial closure (see Chapter 37).
Closure of this defect by direct methods is dif cult. Experience in the closure of ab-
dominal wall ventral hernias has shown that small defects may be repaired primar-
ily with an acceptable recurrence rate if local tissue of suf cient strength can be re-
cruited from the periphery without undue tension. However, for more complicated
defects of any signi cant size (greater than 4 cm), the use of prosthetic material
must be considered.
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Chapter 7
Reoperation for Donor Site Complications

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After conventional bilateral TRAM breast reconstruction, this patient underwent
two attempts at mesh correction of abdominal hernias that failed because of re-
current infection. After the mesh was removed for the second time, obvious hernias
remained.
Because of repeated failure to restore support with the use of prosthetic material,
the decision was made to reconstruct the defect with vascularized muscle and fas-
cia using bilateral rectus femoris musculofascial aps. These aps were tunneled
through the groin skin, sutured across one another, and approximated to the fascial
margin of the hernia.

163
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Postoperatively stable correction of the hernias was achieved. Although the addi-
tional donor site scars and muscle sacri ce are clear disadvantages of this approach,
under these uncommon circumstances it is usually best to implement a surgical
plan that stands the greatest chance of producing a successful functional result.
A variety of materials and techniques have been described for closure of ventral
hernias and are discussed further in Chapter 44.The method of Stoppa has demon-
strated the lowest recurrence rate when used for repair of recurrent and large ven-
tral hernias.46 True abdominal wall hernias should be repaired in all cases;however,
areas of weakness or eventrations should be repaired only at the patient’s request and
provided there have been no intervening health problems that would unacceptably
elevate the risk of further complications.
In cases in which prosthetic material is not an option because of either infection
risks or prior problems with prosthetic material, repair of the TRAM ap donor site
can be achieved with rectus femoris aps. This reconstructive option will provide
innervated dynamic muscle with a strong fascial component and has been found to
provide good support in reported clinical cases.47 However, recurrence rates for au-
togenous tissue repair using aps are not well documented because no large series
comparing this method to prosthetic repair has been published. In addition, the
TRAM flap is usually performed in patients who do not desire additional scar-
ring along the anterior thighs, so this option should really be viewed as a “last re-
sort” approach.
C
o
u
r
t
e
s
y

T
.
A
.
G
i
l
l
i
a
n
,
M
D

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This 55-year old patient presented 1 year after bilateral mastectomies and radia-
tion therapy to the right chest wall for carcinoma of the right breast and left pro-
phylactic mastectomy.
Six days after undergoing bilateral breast reconstruction with bilateral free TRAM
aps, the patient had a violent coughing episode. She felt a “pop” in her abdomen,
which immediately began to swell. Surgical reexploration of the abdominal wound
revealed a large hematoma and complete dehiscence of the fascial closure on both
sides.

It was not possible to reclose the fascial defects primarily;therefore a large sheet of
Prolene mesh was placed as an onlay. The wound was thoroughly irrigated and
drained.
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Chapter 7
Reoperation for Donor Site Complications
The patient healed uneventfully without infection and is shown symptom free at
4 months.

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Inferior Gluteal Free Flap
Experience with the inferior gluteal free ap is limited in most centers, and prob-
lems with the donor site have been mostly cosmetic. However, because of its loca-
tion, this donor site is susceptible to increased tension during hip exion and sit-
ting. Acute wound dehiscence can be managed with reclosure. However, if excess
tension still exists or if the wound has become contaminated or infected, then heal-
ing by secondary intention should be allowed. The site can then be revised at a
later date.
This course of action was taken to treat the donor site problem of this woman,
who had undergone free gluteal breast reconstruction.
Postoperatively, the donor site underwent dehis-
cence and became contaminated.The wound was
allowed to heal by secondary intention.
Closure of the dehisced wound, if clean, can be
obtained using a posterior thigh ap or a tensor
fascia lata ap, as would be done for ischial pres-
sure sores in ambulatory patients.48,49

OSSEOUS AND O STEOCUTANEOUS FLAPS
The most commonly used osteocutaneous aps are radial forearm, iliac crest, bula,
and scapula. Complications not speci c to a particular osseous and osteocutaneous
ap that may require reoperation are the same as those for muscle and musculocu-
taneous aps: wound dehiscence, infection, seroma, and hematoma. Principles of
management of these problems are also the same. However, there are some osteo-
cutaneous ap donor sites that are not amenable to skin grafting, such as the scapu-
lar area. Obviously, any area in which bone is exposed is not amenable to skin graft-
ing. Therefore a secure primary closure of the donor site is important in the
management of dehiscence in these regions, and local aps are required for closure
in many cases.15,23 Also, in the presence of infection, the bone should be thoroughly
evaluated for osteomyelitis and debrided if necessary.
Radial Forearm Osteocutaneous Flap
167
Chapter 7
Reoperation for Donor Site Complications
A high incidence of radius fracture is associated with the radial forearm osteocuta-
neous ap. Bardsley et al25 suggested that such fractures can be minimized by in-
cluding less than 40% of the diameter of the radius in the ap. In addition, the bone
should be beveled at both ends rather than step cut to avoid producing a weak
point in the radius that may be susceptible to fracture.
If this ap is used, a long arm cast should be applied and maintained for at least
6 weeks postoperatively.When radial fractures occur in this setting, they frequently
require open reduction and internal xation for proper alignment.
Radial
vascular
bundle
(Hand)
(Elbow)
Intramuscular
septum
Insertion of
pronator teres
muscle
No
Yes

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Boyd et al52 compared the radial forearm ap with the deep circum ex iliac artery
ap, pointing out the relative advantages and disadvantages. They concluded that
these aps are complementary techniques in oromandibular reconstruction.
Iliac Crest Free Flap
First described by Taylor et al,53 the iliac crest osseous ap, or osteocutaneous ap,
based on the deep circum ex iliac artery (DCIA), is a ap favored by many sur-
geons for oromandibular reconstruction. As an osteocutaneous ap, it is quite bulky
and lends itself well to the repair of large soft tissue defects, particularly in those pa-
tients who must undergo total or subtotal glossectomies as part of composite resec-
tion. A secondary ap-thinning procedure is often necessary in a substantial per-
centage of patients. A study by Boyd et al52 pointed out the detriment of this bulk
when the ap is used in small composite defects, and it showed that there is a higher
incidence of intraoral wound breakdown and bone exposure in DCIA ap recon-
structions than with radial forearm osteocutaneous ap reconstructions.The bone
shape of the iliac crest is similar to that of a hemimandible, making the iliac crest
free ap a good choice for a bone-only ap.The thickness of the bone transferred
with this ap makes osteointegrated implants feasible. Forrest et al53 recently re-
viewed donor site complications after iliac crest free ap transfer.They found that
in the rst 6 postoperative weeks, pain is by far the most common complaint. Late
complications included anesthesia or paresthesia in the lateral and anterior thigh,
contour irregularity, and hernia.
The iliac crest donor site is susceptible to abdominal wall herniation.53 Repair of
this hernia is indicated. Because of the dif culty in reapproximating the adjacent
anatomy, it is recommended that prosthetic mesh or a Gore-Tex patch be used for
repair54 (see Chapter 44). In addition, femoral nerve palsies have been reported at
this donor site and are likely secondary to the placement of retractors on the
femoral nerve at the time of pedicle dissection.6 Because this condition is probably
a neurapraxia, there is no indication for reoperation.
Free Fibula Flap
Fortunately, complications with the free bula ap are rare, and reoperative indica-
tions are uncommon.55 Potentially, however, distal vascularity could be impaired if
the arterial trifurcation is damaged. Other possible problems are damage to the pe-
roneal nerve (in its super cial position adjacent to the neck of the bula), ankle in-
stability (if too much of the distal bula is resected—7 cm should remain), valgus
deformity in children, and neuroma formation (at the site of the transection of the
super cial sensory nerves).56,57 Some investigators have reported a higher incidence
of problems on late follow-up and thorough evaluation with gait analysis.56-59 Only
4 of 10 patients in one study were truly asymptomatic, whereas the others exhib-
ited abnormal stride characteristics, joint angles, and ground reaction forces as well
as altered centers of pressure. Three of these patients demonstrated partial lateral
popliteal nerve palsies (one permanent), and one patient had chronic pain.56 Despite
these problems, reoperative indications were not found.

Scapular Osteocutaneous Flap
The scapular osteocutaneous ap is harvested from a very favorable donor site with
minimal morbidity.60,61 Reoperative indications are rare beyond problems associ-
ated with inability to close the donor site, wound infection, and dehiscence. In
general, open wounds at this site should be treated with dressing changes, and they
should be allowed to close by secondary intention since skin grafting in this area is
dif cult because of shoulder motion. Occasionally a pseudobursa can develop that
may be chronic; in this case, reexploration and obliteration may be required. The
free scapular skin island can be expanded to facilitate wound closure and to enlarge
the size of the donor skin island. Most reoperative indications in this situation re-
late primarily to the complications associated with tissue expansion such as expo-
sure or infection of the periprosthetic space. For donor site complications such as
distal scapular bone viability and postoperative shoulder immobility, reoperation is
not indicated.These problems can be prevented by careful attention to anatomy in-
traoperatively for the former and an appropriate program of physical therapy for the
latter. Immobilization of the shoulder for a period of not longer than 1 week usu-
ally will not interfere with shoulder mobility and can help to avoid potential wound
separation problems in patients undergoing tight donor site closures.62
Shoulder problems may also be exacerbated when portions of the scapula are har-
vested with either the trapezius, scapula, or serratus anterior aps. Long-term pain
and stiffness may require prolonged physical therapy.To avoid scapular instability af-
ter the harvesting of portions of the scapula, the surrounding muscle groups can be
attached to the periosteum of the remaining bone with heavy sutures. The teres
major muscle will provide good lateral stability. Also, the upper ve slips of the ser-
ratus anterior muscle must not be detached from the medial border of the scapula
or “winging” will occur.
ORGAN TRANSFERS
BOW EL
Donor site morbidity after the harvest of a free bowel segment for esophageal re-
construction is the same as for bowel resection.These problems include wound in-
fection, anastomotic dehiscence, bowel obstruction, peritonitis, fasciitis, hernia for-
mation, stricture, stula formation, and even death. Most reoperative indications
for this type of surgery are within the realm of the general surgeon. However, any
plastic surgeon who harvests tissue from this area should be trained in abdominal
surgery and be capable of dealing with potential complications. Reoperative indi-
cations for hernia formation and techniques for repair are discussed in Chapter 44.
Signs of early bowel obstruction consist of crampy abdominal pain, abdominal dis-
tention, obstipation, and vomiting. An anastomotic dehiscence with subsequent in-
traabdominal abscess is the most serious complication associated with free bowel
transfer. Symptoms are signs of toxicity, fever, elevated white blood cell count, per-
sistent and more localized abdominal tenderness, and persistent ileus. Both small
bowel obstruction and intraabdominal abscess should be explored expediently. Ad-
hesiolysis with decompression is necessary to treat bowel obstruction, whereas
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drainage is indicated for intraabdominal abscess. Reoperative indications for fasci-
itis are addressed in Chapter 44.
Omentum, another source for intraabdominal aps, has donor site morbidity sim-
ilar to that of free bowel transfers: small bowel obstruction, wound dehiscence, or
late hernia. However, one form of bowel obstruction unique to omental pedicle
aps is gastric outlet obstruction when the ap is based on the right gastroepiploic
artery.This problem may require reexploration and decompression.63
TOE TRANSFER
The ability to reconstruct an absent thumb by transfer of a toe has become a com-
mon procedure. Three types of transfer are possible: complete great toe transfer, a
wraparound flap, and second toe transfer.64 The wraparound flap is designed to
leave a greater amount of tissue at the donor site, thus minimizing donor site mor-
bidity.65 Obvious donor site morbidity is seen cosmetically, especially with great
toe transfers, and the harvest of the toe can interfere with gait. However, reopera-
tion is indicated usually only for morbidity associated with pain or infection. Pain
may be caused by hyperkeratotic lesions on the plantar surface resulting from clo-
sure with skin grafts. Although it is best to avoid the development of these lesions
by performing direct closure of the plantar skin at the initial procedure, the lesions
can be managed secondarily by excision and closure either primarily or with local
flaps. Ulceration is uncommon and if present is usually associated with poor-
quality coverage, which may require reoperation to transfer more durable skin to
the donor site. Neuromas in this area are managed similarly to those in the upper
extremity with exploratory surgery, repair, grafting, or relocation of the nerves into
muscle or bone.9,10
Infection of this donor site requires open drainage with delayed primary closure or
closure over drains if bone is exposed. Elevation of the foot and intravenous antibi-
otics are also indicated.
UNSOLVED PROBLEMS
Donor site morbidity will continue to remain dif cult to manage until more sur-
geons are forthcoming in reporting the problems they encounter. Historically sur-
geons are reluctant to report what they may consider their own failing, yet by not
sharing this information, they may miss an opportunity to realize that their so-
called failure is simply a common pitfall inherent in a challenging donor site.They
also miss the opportunity to combine their efforts with those of other surgeons to
nd solutions to these pitfalls. Such has been the case with the recent reporting of
brachial plexus injury associated with free ap breast reconstruction.49 After our
report, we found that surgeons at other major centers were experiencing similar
problems. By combining our efforts, we have now arrived at a reasonable plan to
help us and others avoid this problem in the future.

The dif culty in compiling the data for this chapter is testimony to the fact that ei-
ther we are all such outstanding surgeons that donor site morbidity requiring sec-
ondary reoperation is very rare, or we do not report it often.We would hope for the
former, but we suspect the latter.
References—With Key Annotated References
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4. Thaller SR, Kim JC, Kawamoto HK. Calvarial bone graft donor site:A histological study in a
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12. Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004.
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constr Surg 81:21, 1988.
16. Leighton WD, Russel RC, Feller AM, et al. Experimental pre-transfer expansion of free ap
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22. Mackay DR, Saggers GC, Kotwal N, et al. Stretching skin: Undermining is more important
than intraoperative expansion. Plast Reconstr Surg 86:722, 1990.
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24. Goldwyn RM, Rueckert F.The value of healing by secondary intention for sizeable defects of
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25. Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial forearm ap donor site.
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26. Swanson E, Boyd JB, Manktelow RT. The radial forearm ap: Reconstructive applications in
donor site defects in 35 consecutive patients. Plast Reconstr Surg 85:258, 1990.
This excellent article was one of the early published papers to examine this versatile donor site for free
tissue transfer.
27. Swanson E, Boyd JB, Mulholland RS.The radial forearm ap:A biomechanical study of the os-
teotomized radius. Plast Reconstr Surg 85:267-272, 1990.
28. Timmons MJ, Missotten FEM, Poole MD, et al. Complications of radial forearm ap donor
sites. Br J Plast Surg 39:176-178, 1986.
29. Fenton OM, Roberts JO. Improving the donor site of the radial forearm ap. Br J Plast Surg
38:504, 1985.
30. Jones BM, O’Brien CJ. Acute ischemia of the hand resulting from elevation of a radial fore-
arm ap. Br J Plast Surg 38:396, 1985.
31. McGregor AD. The free radial forearm ap: The management of the secondary defect. Br J
Plast Surg 40:83, 1987.
32. Dellon AL, Mackinnon SE.The pronator quadratus muscle ap. J Hand Surg Am 9:923, 1984.
33. Kupfer D, Lister G.The pronator quadratus muscle ap: Coverage of the osteotomized radius
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34. Weinzwerg N, Chen L, Chen ZW. Reverse radial forearm fascial ap with preservation of the
radial artery for coverage of the hand. Presented at the Annual Meeting of the American
Society of Plastic and Reconstructive Surgery,Washington, DC, Sept 1992.
35. Meland NB, Maki S, Chao EYS, et al.The radial forearm ap:A biomechanical study of donor
site morbidity utilizing sheep tibia. Plast Reconstr Surg 90:763, 1992.
36. Meland NB, Core GB, Hoverman VR. The radial forearm ap donor site: Should we vein
graft the artery? A comparative study. Plast Reconstr Surg 91:865, 1993.
37. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm ap: Anatomy and clinical
applications. Ann Plast Surg 12:489, 1984.
38. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free ap. Plast
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Following this paper, new interest was generated in the use of this thin ap for the hand, foot, and
face where thin coverage was required.
39. Baker DC, Conley J. Regional muscle transposition for rehabilitation of the paralyzed face.
Clin Plast Surg 6:317, 1979.
40. Colen SR,Shaw WW, McCarthy JG. Review of the morbidity of 300 free ap donor sites. Plast
Reconstr Surg 76:948, 1986.
41. Maruyama Y, Iwahira Y. Correction of donor site defect with the reverse latissimus ap. Plast
Reconstr Surg 80:848, 1987.
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Plast Surg 7:49-57, 1993.
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tive evaluation of 335 patients. Perspect Plast Surg 1:123, 1987.
44. Waymack J, Pruitt BA Jr. Burn wound care. Adv Surg 23:261, 1990.

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is now widely used for complex hernias of the abdominal wall.
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51. Tobin GR, Pompi-Sanders B, Man D, et al. The biceps femoris myocutaneous advancement
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54. Forrest C, Boyd B, Manktelow R, et al.The free vascularized iliac crest tissue transfer: Donor
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thop Relat Res 80:130, 1971.
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57. Hidalgo D. The bular free ap: A new method of mandible reconstruction. Plast Reconstr
Surg 84:71, 1989.
58. Lee EH, Goh JCH, Helm R, et al. Donor site morbidity following resection of the bula. J
Bone Joint Surg Br 72:129-131, 1990.
59. Wiltse LL.Valgus deformity of the ankle: A sequel to acquired or congenital abnormalities of
the bula. J Bone Joint Surg Am 54:595, 1972.
60. Kimura N, Minami A, Takahara M, et al. Donor site morbidity following free vascularized
bular transfer [abstr]. J Reconstr Microsurg 9:467, 1993.
61. Takemoto S, Ikuta Y. Donor site morbidity after vascularized bone graft [abstr]. J Reconstr Mi-
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63. Sullivan MJ, Baker SR, Crompton R, et al. Free scapular osteocutaneous ap for mandibular
reconstruction. Arch Otolaryngol Head Neck Surg 115:1334, 1989.
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1994.
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1. Many donor sites share the following similar potential complications, with the
exception of:
a. Hematoma
b. Carpal tunnel syndrome
c. Seroma
d. Pain
e. Deformity
2. A patient who just underwent harvesting of a rib cartilage graft for ear recon-
struction exhibits shortness of breath in the recovery room.The best treatment
option is:
a. Sedation
b. Increased oxygen ow
c. Chest radiograph to rule out pneumothorax
d. Elevate the head of the bed
e. Increase intravenous hydration
3. Reoperative management of a painful neuroma includes:
a. Repair of the nerve in continuity with its distal remnant
b. Secondary nerve grafting
c. Implantation of the proximal nerve into adjacent muscle or bone
d. Trimming the nerve back more proximally
e. All of the above
4. To prevent brachial plexus injury during any surgery that requires arm abduc-
tion, you should:
a. Rotate the head to the opposite side
b. Place the arm at 100 degrees from the side of the body
c. Fully externally rotate the elbow
d. Place the forearm in the neutral position (neither pronated nor supinated)
e. Flex the neck forward
5. Abdominal skin necrosis after TRAM ap surgery should be managed as follows:
a. Aggressive reexcision of eschar and readvancement of the ap
b. Hyperbaric oxygen
c. Tissue expansion
d. Conservative debridement of demarcated eschar
e. Immediate vacuum-assisted closure of the wound
R EVIEW QUESTIONS