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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Once again, after successful wound closure was obtained with restoration of soft tis-
sue mass, the secondary tendon transfer proceeded as it might have for an isolated
nerve injury alone. All principles of tendon transfer were heeded, with the inter-
posed free ap serving to normalize the initial soft tissue de cit.
TENOLYSIS
In speci c circumstances in which tendon reconstruction was accomplished pri-
marily under free tissue transfers, limited elevation or direct incision of the ap for
release of underlying tendon adhesions may be safely accomplished. In keeping
with the established principles of secondary tendon surgery, this procedure should
not be attempted until passive range of motion of all joints and maturation of all
scar tissue have occurred. Because of localized anesthesia in the ap bed, tenolysis
can often be carried out with the patient under minimal anesthesia, which allows
the patient to test the tenolysis in real time on request by the surgeon.
Patient Example
This 43-year-old right-hand–dominant patient presented with an avulsion injury to
the dorsum of the left hand.This injury destroyed the skin and subcutaneous tissues,
caused untidy lacerations of the entire extensor digitorum communis muscle com-
plex, and stripped the underlying periosteum and cortices of the index through
the ring metacarpal bones.
Primary debridement and revised tendon ends

Temporoparietal fascia
superficial layer
Temporoparietal fascia
Deep temporal fascia
Temporalis
muscle
2027
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Composite reconstruction was performed in a single stage by the transfer of a bilam-
inar temporoparietal fascial ap and primary suture of the partially debrided and re-
vised tendon ends. A skin graft was applied over the super cial layer of the tem-
poroparietal fascia and the wound was splinted. Once wound closure was ensured
and the skin graft had completed its epithelialization, the patient began an extended
course of joint mobilization.

2028
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With the patient under local anesthesia and with a tourniquet placed, a small lon-
gitudinal incision was made in the midbody of the temporoparietal ap. Tenolysis
was undertaken and the patient was then asked to pull through on the extensor
tendon reconstruction. Once the patient demonstrated restoration of active motion,
the tourniquet was let down. Hemostasis was achieved and the wound was closed.
The patient returned to the therapist shortly after surgery for continued postoper-
ative rehabilitation including maintenance of the newly achieved range-of-motion
and active-resistance exercises designed to strengthen the extensor digitorum com-
munis musculotendinous units.
Four months postoperatively, passive
range of motion of the wrist and nger
joints had returned to a near-normal
level. However, active range of motion
was impeded by tendon scarring at the
site of tendon juncture.

SECONDARY NERVE GRAFTING
In composite injuries to the upper extremity that disrupt major peripheral nerves,
distal and proximal mobilization for advancement and primary suture of nerve ends
is limited to the repair of small segmental defects measuring not more than 2 to 3 cm.
It has been well-proven by Millesi that nerves repaired primarily under tension
have a poorer functional return than nerves treated with interpositional nerve graft-
ing. Long segmental defects associated with overlying soft tissue loss presage a poor
prognosis, regardless of the surgical option used for reconstruction. Bridenback and
Terzis underscore the importance of improving the vascular bed of the nerve graft
for optimal axonal regeneration.They have performed and reported on a series of
interpositional nerve grafts performed for this purpose. An alternative method of
nerve repair is the primary reconstruction of the soft tissue defect with a vascular-
ized ap followed by reelevation of the ap for interpositional nerve grafting using
nonvascularized autogenous sural nerve.
Patient Example
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Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
This 37-year-old patient presented with a gunshot wound to the left antecubital
fossa. The injury resulted in loss of medial and posterior skin, a 9 cm loss of ulnar
nerve, and destruction of both the medial epicondyle of the olecranon and the dis-
tal humerus (type IIIb fracture). Initial stabilization was accomplished with an AO
external xation device, and debridement was performed to remove all nonviable
soft tissue and bone.

2030
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Fracture reduction was subsequently completed with conversion of the external
fixation to a combination of posteriorly placed reconstruction plates on the
humeral condyles. A pedicled latissimus dorsi musculocutaneous ap was simulta-
neously transferred to cover the defect.
Shortly thereafter nerve reconstruction using multiple sural nerve grafts facilitated
by limited ap elevation was performed. At the time of nerve grafting the soft tis-
sues appeared clean and well vascularized.

FLAP ELEVATION FOR SECONDARY ILIAC CREST
BONE GRAFTING
One of the most common secondary procedures after ap transfer in the extrem-
ities is limited but direct reexposure of a comminuted fracture site for subsequent
iliac crest bone grafting.12,13 The orthopedic literature has clearly documented the
need for secondary bone grafting to augment the eventual union of type IIIb frac-
tures in both the upper and lower extremities.14 Although early coverage of these
complex fractures with vascularized soft tissue has signi cantly decreased the unto-
ward sequelae of infection,15-17 there are no data to support the idea that soft tissue
coverage alone imparts increased potential for decreased time to bony union.The
restoration of a vascularized soft tissue envelope, however, has allowed the orthope-
dic traumatologist to bone graft directly at the fracture site in a timely fashion. Be-
fore the advent of ap coverage of these types of injuries, the standard practice was
to indirectly bone graft through a separate posterior approach. Posterior lateral
bone grafting for the treatment of type IIIb tibial fractures was hampered by (1) the
long delay in attempting to achieve closure of the primary wound by secondary in-
tention, and (2) biomechanically by application of the bone graft in an area other
than the direct diaphyseal shaft defect.
Although simultaneous iliac crest bone grafting and vascularized wound closure
have been reported with favorable results, the accepted standard of treatment at this
time is early secondary iliac crest bone grafting 4 to 6 weeks after successful wound
closure. The procedure is performed with participation by both the orthopedist
and plastic surgeon. With the extremity under tourniquet control, the previously
transferred ap can be elevated with care taken to maintain the vascular pedicle.
Any muscle component that is used for the obliteration of the osseous dead space
can then be directly excised.The iliac crest bone graft is packed into the osseous de-
fect directly, obliterating the diaphyseal defect completely.Wound cultures are taken
to determine whether any persistent deep space infection is present. A positive cul-
ture might then alter the postoperative antibiotic strategy.The ap is resutured un-
der tourniquet control after the placement of drains. It is not recommended to re-
lease the tourniquet before wound closure after iliac crest bone grafting because the
rapid onset of ap swelling would impair wound closure and compromise the pri-
mary objective. Appropriate bulb suction drainage allows for the evacuation of any
residual bleeding under the ap.
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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Patient Examples
This 41-year-old right-hand–dominant construction worker presented with a type
IIIb fracture of the radius and ulna in the right upper extremity after a crane boom
fell on his dominant arm. Injuries included a comminuted fracture of the midbody
of the ulna, a 6 cm loss of the middle and distal radius, and the loss of nearly the en-
tire extrinsic extensor compartment and the majority of the overlying skin and sub-
cutaneous tissue. Initial stabilization was accomplished using an AO external xa-
tion device accompanied by radical debridement of all nonviable structures. Initial
wound coverage was achieved 72 hours after the injury using a rectus abdominis
muscle ap covered with split-thickness skin grafts. A frame extension was applied
to the distal pins for the application of an outrigger splinting device.This maneu-
ver allowed therapists to begin the process of early joint mobilization and mainte-
nance of exor function.

Eight weeks after the injury, the patient was returned to the operating room for
massive iliac cancellous bone grafting and reconstruction plating of both the radius
and ulna. Flap elevation was accomplished without incident. The external xator
was maintained for an additional 4 weeks to maximize the passive range of motion
of the wrist and nger joints.The device was then removed in the of ce with the
patient under local anesthesia.
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2034
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Six months after the bone grafting, the patient was returned to the operating room
once again for a modi ed Brand, Starr,Tsuge tendon transfer for the restoration of
wrist, nger, and thumb extension.
Therapy continued for several months with resultant fracture healing, wound clo-
sure, and good restoration of wrist and nger extension using the pronator teres and
exor carpi radialis muscles, respectively. The patient returned to light modi ed
work 16 months after initial injury.

This 31-year-old patient was treated for a type IIIa tibial fracture with primary
plating and wound closure. Several weeks after the initial surgery, the wound broke
down, with drainage of purulent material. Debridement with removal of the inter-
nal xation device resulted in an open wound with bony nonunion.
2035
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After transfer to our facility several months later, a radical en bloc excisional de-
bridement was undertaken followed by free ap transfer using the rectus abdominis
muscle and split-thickness skin graft.

2036
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R EOPERATIVE SURGERY OF THE EXTREMITIES
Six weeks after wound closure, the patient was returned to the operating room
where the rectus abdominis ap was raised on a vascular pedicle under tourniquet
control to allow simultaneously harvested iliac crest cancellous bone graft to be
placed. Close attention was paid to the maintenance of the vascular anastomoses.
The component of the ap that had been used to obliterate the diaphyseal dead
space was excised to accommodate the cancellous bone graft. Drains were placed
and the ap was resutured before the release of the tourniquet.The overlying skin
graft on the rectus abdominis muscle remained undisturbed throughout the reele-
vation procedure.
Bony union was achieved with complete wound closure and no subsequent evi-
dence of drainage.The patient is now fully ambulatory without bracing or assistive
devices.
This 53-year-old patient presented after a dev-
astating type IIIb plafond fracture to the ankle.
Initial attempts at internal xation and wound
closure resulted in infection and further soft tis-
sue loss. Because of the complex nature of the
fracture with an extensive intraarticular compo-
nent, internal xation was left in place despite
continued drainage. The patient underwent a
prolonged course of antibiotic therapy that re-
sulted in a superinfection with Aspergillus or-
ganisms.

On transfer to our facility, the patient was switched to antifungal medications and
taken to surgery for a wide en bloc radical debridement of all involved structures.
Two subsequent debridements were required to arrest the continued, ongoing
necrotizing process.
2037
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Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
Once the wound was stabilized, a rectus abdominis ap was transferred for wound
coverage and complete obliteration of dead space. A split-thickness skin graft was
simultaneously performed. Antifungal agent therapy was continued for an addi-
tional 6 weeks.

2038
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Three months postoperatively, the patient was returned to the operating room for
extensive cancellous bone grafting and ankle fusion. The ap was elevated away
from the site of the anastomoses and a deep portion of the ap was removed to ac-
commodate the bone graft. A radiograph of the residual osseous defect is shown.
Drains were placed and the ap was resutured before tourniquet release. Marked
shrinkage of the ap had occurred in the 3 months between initial transfer and
reelevation.The reelevated ap is shown.
The patient has achieved solid ankle fusion with no recurrence of drainage or other
signs of infection. Continued atrophy of the ap has occurred, and the patient is
now able to wear a tennis shoe.
VASCULARIZED BONE TRANSFER AFTER
SOFT TISSUE COVERAGE
Occasionally a type IIIb fracture of the upper or lower extremity results in not
only massive skin and soft tissue loss but also long segmental cortical defects in the
diaphysis that are not amenable to repair by iliac crest bone grafting alone. Accord-
ing to classic reconstructive principles, 6 cm is the limit for bone grafting; beyond
this point cancellous bone grafting alone is considered insuf cient for successful
bony union and preservation of extremity length. Isolated reports have documented
successful fracture healing under free tissue transfers of defects up to 12 cm with
nonvascularized cancellous bone graft. However, most surgeons favor either vas-

cularized long bone transfer using the bula or, more recently, using the Ilizarov de-
vice for compression osteosynthesis with subsequent, or in some cases simulta-
neous, distraction via distant corticotomy.Vascularized bula transfer has been pop-
ularized by Weiland and Daniel18 and has since been reported by multiple centers
for numerous applications.19 Modi cation of the bula transfer has allowed the ad-
dition of soleus muscle and/or overlying skin panels for soft tissue augmentation. In
our hands wound closure with muscle or musculocutaneous ap transfer provides
the most favorable environment for the subsequent microvascular transfer of the
bula. Before osteosynthesis using the interpositional bula is performed, it is im-
portant to ascertain the correct length of the defect, with the injured extremity
being held out to its normal length using external xation devices.
In the upper extremity the latissimus dorsi ap has served nicely to quickly and
completely cover complex humeral defects without requiring microvascular anas-
tomoses. Injuries to the forearm that require signi cant soft tissue coverage, with
the expectation of future long bone interpositional bula transfer, usually require
early free muscle or fasciocutaneous ap transfer for wound coverage. Similarly in
the lower extremity, diaphyseal defects that are more proximally located can be ini-
tially covered with rotational aps of either gastrocnemius or soleus muscles. In-
juries of the distal third of the tibia rst require wound coverage using muscle or
musculocutaneous aps as free tissue transfers. Muscle or fasciocutaneous ap ele-
vation must be extensive to permit complete visualization of the osseous defect
with adequate distal and proximal exposure to allow various combinations of plate
and screw xation across each fracture site. An additional sleeve of bular perios-
teum is harvested from the distal and proximal ends at the transection site to allow
the osteosynthetic site to be wrapped at the recipient defect.
Various options for osteosynthesis include (1) long reconstruction plating incorpo-
rating both the proximal and distal native humerus as well as the bula, (2) dual
short reconstructive plating of each osteosynthetic site separately, and (3) screw x-
ation with augmented external xation performed with either a tongue and groove
technique or a step-cut technique. Finally, cross-Kirschner wire xation along with
supplemented external xation can be used, but is discouraged because it does not
provide enough strength and stability.
Problems with bular fracture have included late refracture at one of the two os-
teosynthetic sites or osteoplastic deformation. Both results require an additional re-
vision surgery for bone graft augmentation and plating at the failed osteosynthetic
site. Despite these occasional late complications, all bular transfers that we have
performed later achieve complete healing.
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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Patient Examples
This 17-year-old patient presented with a gunshot wound to the left middle and
proximal humerus.Through-and-through soft tissue loss and segmental loss of the
middle and proximal humerus occurred. Overlying skin was destroyed as well as
signi cant distances of the radial and median nerves.
The distal upper extremity remained vascularized. Initial stabilization was achieved
using AO external fixation with debridement of nearly 11 cm of diaphyseal
humerus.The radiograph demonstrates the extensive osseous loss of the humerus.

The ipsilateral latissimus dorsi muscle was transferred as a pedicled musculocuta-
neous ap, allowing early wound closure.
2041
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Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
The patient was returned to surgery 2 months postoperatively for the transfer of an
interpositional bular osteocutaneous ap. This ap was xed with both external
xation and internal screw xation. Fracture healing occurred at the proximal and
distal osteosynthetic sites.
After increased use, however, a refracture occurred at the proximal site. Subsequent
reelevation of the latissimus dorsi musculocutaneous ap, plate xation, and aug-
mentation with an iliac crest bone graft were required. With healing, complete
bony union of the humerus was achieved. Continued occupational therapy revealed
a persistent radial nerve de cit for which the patient received radial nerve transfers.
Harvest of bular osteocutaneous ap
Fibular osteocutaneous ap inter-
posed for humeral reconstruction

2042
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
This 27-year-old patient presented with a type IIIb midthird tibial fracture of the
right lower extremity with loss of 10 cm of the tibial shaft.
Initial wound closure was achieved using a soleus muscle transposition ap (be-
cause surprisingly the soft tissue defect was much smaller than the osseous one)
and a split-thickness skin graft. Length and alignment were obtained with an AO
half-frame external xator.

Eight weeks after wound coverage, with no evidence of infection, the contralateral
bula was transferred as a vascularized ap.The outlined ap is shown as well as the
initial incision revealing the posterior intercural septum. Note the septal vessels
supplying the skin paddle. A combination of maintained external xation and in-
ternal screw xation was used to stabilize the transfer. Successful union occurred at
both osteosynthetic sites.The patient was progressively ambulating.
2043
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Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
The bular osteocutaneous ap was isolated in situ. The ap is shown ready for
transfer. A radiograph of the ap interposed for tibial reconstruction is also shown.

2044
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Three months after the ap was transferred and before the external xation was re-
moved, some bular hypertrophy was noted.
Six months after the bular transfer, the proximal osteosynthetic site was noted to
have undergone osteoplastic deformation with valgus angulation.
This defect was corrected by a second reelevation of the soleus muscle, and os-
teotomy with plating of the proximal healed osteosynthetic site.The patient even-
tually achieved full weight–bearing, unassisted ambulation with complete bony
union.

ILIZAROV APPLICATION AFTER FREE TISSUE TRANSFER
As orthopedists have gained experience using the Ilizarov device, distraction and
compression osteosynthesis using bony transport has allowed the correction of large
segmental diaphyseal long bone defects without the need for distantly harvested
bone graft. Osseous defects of considerable length can be obliterated by slow but
steady bone transport using a series of ring guides and ne-wire xators. A distant
corticotomy is performed in the proximal uninjured tibia or humerus, allowing
distraction of the cortex toward the bony portion of the de cit. Once the defect is
obliterated, compression osteosynthesis can be performed. Most complex open
fractures that result in segmental bone defects are accompanied by signi cant over-
lying skin and subcutaneous tissue loss. Early wound closure allows more rapid un-
dertaking of Ilizarov distraction, resulting in a shorter time to bony union. Both
pedicled and free tissue transfers have been liberally used in association with the
Ilizarov frame.9 Fine-wire xation devices can be placed directly into the ap sub-
stance without fear of ap compromise. Problems with the progressive transport of
the device through the ap have not been reported. If muscle aps are used initially
to obliterate deep osseous dead space, that part of the ap might interfere with the
ultimate docking of the two bone ends. A small revision requiring elevation of that
section of the ap might be required and should be performed as close to nal
bony contact as can be afforded. If the Ilizarov device is to be used before or simul-
taneous with the placement of a muscle ap, consideration should be given to the
location of the vascular pedicle for access with the initial anastomoses and in the
case of potential revision.
Patient Example
2045
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
This 32-year-old patient sustained a type IIIb
midthird tibial fibular fracture and was initially
treated with internal fixation using plates and
screws.This site became infected, so the internal
hardware was removed and an external xation
device was placed. A series of incisions and de-
bridements led to the eventual formation of a si-
nus tract and hypertrophic nonunion 21⁄2 years
after the injury.

2046
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
At this point the patient underwent radical debridement with subsequent transfer
of the rectus abdominis muscle with overlying split-thickness skin graft for obliter-
ation of dead space. The external xator was converted to an Ilizarov device, and
the resected hypertrophic nonunion was then obliterated and compressed to gain
bony union. Fine-wire xation pins were placed through the substance of the ap
and transport occurred without any deleterious effect to the soft tissues.
Union was achieved both clinically and radiologically 3 months after application of the
device.The radiograph demonstrates the successful docking of the tibial fragments.

FLAP DEBULKING, R EORIENTATION, AND R ECONTOURING
Both fasciocutaneous and muscle aps are now commonly used for lower extrem-
ity reconstruction with great success.19 Of the two types, fasciocutaneous aps tend
to provide an initial superior cosmetic result. With time, however, dependency,
edema, and lack of anchoring to the normal underlying structures may result in
bulky, redundant skin paddles. Residual contour deformities become more pro-
nounced, causing the patient to focus on them as the other, more serious problems
are resolved.These deformities can be minimized somewhat by the application of
compression devices such as Jobe stockings or elastic wrap bandages. Despite these
adjunctive measures, however, most contour deformities of the lower leg do not im-
prove and tend to worsen.20 Functional problems about the ankle or foot can oc-
cur because of dif culty with ambulation and shoe t. Fortunately skin paddle el-
evation for debulking, recontouring, or ap reorientation is quite safe. If skin excess
is not a problem, liposuction can be used to remove unwanted fatty tissue. Few ex-
tra precautions are necessary when performing this procedure. Cannulation in and
around the pedicle should be avoided, if possible.
Patient Examples
2047
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
This 10-year-old patient required en bloc excision of the proximal tibia and all over-
lying skin and soft tissues as the result of a high-grade sarcoma. A custom endopros-
thesis was implanted to replace the tibia and knee joint.Wound closure was achieved
with a rectus abdominis musculocutaneous ap. Because of some truncal obesity,
the musculocutaneous transfer brought with it unwanted subcutaneous tissue.

2048
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Once the patient was well past the 6-month course of chemotherapy with no ev-
idence of local or systemic recurrence, two successive debulking procedures of the
previously placed transfer were performed. The second debulking was performed
6 months after the rst. Each procedure was con ned to the skin and subcutaneous
tissue without any reexploration of the vascular pedicle region. Elevation was con-
ned to no more than half of the circumference of the marginal wound, and wedge
excision of the underlying fat was performed. The second elevation was oriented
toward the opposite side, thus completing the circumferential defatting.
Signi cant improvement in the aesthetic and contour deformities resulted.The pa-
tient is shown 2 years after ap transfer.

This 11-year-old patient presented with a third-degree burn injury of the left dis-
tal thigh, knee, and proximal tibia anteriorly. These wounds were treated with se-
rial debridements and secondary wound contracture and closure. Unstable scars
throughout the burn injury led to secondary breakdown with reinfection along
the distal thigh and knee. Composite excision of the burn wound superiorly was
then followed by transfer of the parascapular fasciocutaneous ap with anastomoses
to the lateral superior genicular artery and vein. One year after transfer, although
the ap remained in place, there was subsequent breakdown of the inferior wounds
over the proximal tibia (top). Full range of motion was retained (middle). Doppler
examination veri ed the patency of the lateral anastomosis of the subscapular ves-
sels (bottom).
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2050
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
This problem was addressed by inferior wound excision and reelevation of the
parascapular ap, with close attention paid to its subtending vascular pedicle. The
pointer indicates the patent vascular pedicle (top). A layer of well-vascularized sub-
cutaneous tissue was left superiorly as the ap was transposed to cover the inferior
wound. Based on the Crane principle, an excellent bed remained superiorly for
the placement of a split-thickness skin graft while the ap was used to close the re-
calcitrant inferior wound without problem. The patient healed without incident.
The wound has remained closed and a full range of knee motion has been retained.

This 27-year-old warehouse worker presented with an avulsion injury of the dor-
sum of the foot, resulting in the loss of skin, subcutaneous tissue, and some toe ex-
tensors. The dorsal metatarsal joints were exposed and initially treated with de-
bridement and a temporoparietal fascia ap with overlying skin graft.Unfortunately,
the ap failed to survive, leaving a chronic open wound. This wound was repeat-
edly skin grafted without success. Six months after the initial injury, we addressed
the problem by using aggressive debridement of the entire wound and transfer of
the parascapular fasciocutaneous ap, which was vascularized by the anterior tibial
artery and vein. Wound closure was achieved with excellent initial inset and con-
tour. However, over the next 4 months, progressive swelling and fullness of the fas-
ciocutaneous ap were noted.This swollen state was made worse with progressive
ambulation, despite the consistent use of compressive wraps.
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2052
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
At the patient’s request, the redundant skin and subcutaneous tissue was elevated
and excised 6 months after the ap transfer.The vascular pedicle was maintained as
well as 50% of the marginal incision between the ap and native tissues. The ap
was reclosed under a moderate degree of tension and a compressive hose was ap-
plied at the time of surgery.This support was worn for 6 weeks postoperatively, and
then changed to a light support hose, which was worn for the next 6 months.The
patient is now able to wear shoes and stockings that were worn before the injury.

Consequently, the patient was taken to the operating room, where excision of all in-
volved skin and soft tissue was performed and the calcaneus was reduced and rigidly
xed with screws. Wound closure was achieved with a gracilis muscle transfer and
split-thickness skin graft. Healing occurred with some initial loss of the skin graft.
Eight months after ap transfer, some shrinkage was noted.The patient had a sheer-
ing sensation over the calcaneus. A contour deformity prevented the patient from
wearing most preinjury footwear. The vascular pedicle was left undisturbed. The
patient was returned to surgery for wedge excision and reclosure of the muscle
ap. A marginal wedge of muscle was removed without dif culty after raising it
2053
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Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
This 33-year-old patient presented with a type IIIb
calcaneal fracture with necrosis of overlying poste-
rior skin. The patient wore a cast for the first 3
weeks after the injury. At the time of the second
cast change, an eschar over the posterior calcaneus
was noted left. Radiographs demonstrated persistent
malalignment at the fracture site.

2054
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R EOPERATIVE SURGERY OF THE EXTREMITIES
intact from the posterior defect. The patient was treated postoperatively with a
compressive device for several weeks, followed by the application of a compressive
elastic bandage for the next 4 months.
Normal contour and shoe t with successful debulking was achieved with minimal
ap reelevation and reorientation.
CONCLUSION
It is to be hoped that the day will come when re nements in reconstructive surgery
allow us to address functional and aesthetic problems in a single operative procedure
with one composite tissue transfer. Isolated but encouraging reports that describe
single-stage comprehensive reconstruction of multiorgan defects are surfacing.21
Presently, however, most injuries that involve multiple structures, including signif-
icant loss of overlying skin and soft tissue, require at least one additional and often
multiple staged secondary procedures to achieve maximal restoration of function
and cosmesis.Vascularity is the most important consideration during the planning
of reoperative procedures in the previously wounded extremities.22 It is generally
accepted that delayed transection of a vascular pedicle and a transferred ap may be
safely performed after an arbitrary period; however, in most circumstances initial
ap transfer was required for a relative lack of vascularity to the wound space. For
this reason, vascular pedicles should be maintained whenever possible during sec-
ondarily operated tissue transfers.There are two reasons that ap elevation for sub-
sequent revision or for further operation to subtending structures should be limited
to only the amount deemed necessary: (1) to maintain maximal blood ow to the
revised ap and (2) to minimize operative trauma to the surgically disrupted tissue
planes.Timing of reoperative ap surgery varies widely with the intended goals of
the procedure. Flaps have been reelevated electively as soon as 2 days after initial
placement and as long as several years after transfer. Reoperation for the restoration
of maximum tendon function is achieved by allowing tissue equilibrium to occur,
a classic rule that applies for all tendon transfers. Patients who undergo ap revision
surgery generally tolerate compression garments very well.These garments should
be worn whenever possible to minimize postoperative swelling.

The most effective way to avoid the problems of secondary or reoperative surgery
after flap transfer in the extremities is to prevent their occurrence initially. This
principle also guides the quest for a universal cure for cancer. As previously stated,
further developments and re nements of free tissue transfer and reconstructive sur-
gery of the extremities have con rmed an important lesson: the more that can be
achieved at the primary operative setting, the less the need for secondary surgery at
the outset.
References—With Key Annotated References
1. Acland RD. Re nements in lower extremity free ap surgery. Clin Plast Surg 17:733-744,
1990.
2. Melissinos EG, Parks H. Post-trauma reconstruction with free tissue transfer: Analysis of 442
consecutive cases. J Trauma 29:1095-1103, 1989.
3. Anthony JP, Mathes S, Alpert BS. The muscle ap in the treatment of chronic lower extrem-
ity osteomyelitis:Results in patients over ve years after treatment. Plast Reconstr Surg 88:311-
318, 1991.
4. Godina M. Selection of recipient vessels in the lower leg for microvascular ap transfer. In
Thesis on the Management of Injuries to the Lower Extremity. Ljublijana,Yugoslavia: Preser-
nova Irbzba, 1991.
5. Feibel RJ, Oliva A, Buncke GM, et al. Soft tissue reconstruction in orthopedic surgery: Sec-
ondary procedures. Orthop Clin North Am 24:537-548, 1993.
6. Chowdary RP, Murphy RX. Delayed debulking of free muscle aps for aesthetic contouring.
Br J Plast Surg 45:38-41, 1992.
7. Tsur H, Daniller A, Strauch B. Neovascularization of skin aps:Route and timing. Plast Recon-
str Surg 66:85-90, 1980.
8. Brandt KE, Howell RL, DeLozier JB, et al. Management of traumatic soft tissue injuries dur-
ing Ilizarov external xation. Plast Surg Forum 14:388-391, 1991.
9. Jupiter JB, Kour AK, Palumbo MD, et al. Limb reconstruction by free-tissue transfer combined
with the Ilizarov method. Plast Reconstr Surg 88:943-951, 1991.
10. Black MJ, Chait L, Sykes P, et al. How soon may the axial vessels of a surviving free ap be
safely ligated: A study in pigs. Br J Plast Surg 31:295-299, 1978.
In four complex cases of extremity reconstruction, the authors reported overcoming the problems of com-
bined bone and soft tissue loss and length discrepancy by a combination of free tissue transfer and the
Ilizarov method of slow distraction.They observed that gradual distraction of free tissue is a safe and
viable procedure;the free tissue tolerates the pins of the circular external xator well, and there is an
equal degree of distraction and regeneration of the transferred free tissue and the native recipient tis-
sue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to
vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Ma-
nipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for
later microsurgical procedures or endanger the axial ow pattern of the transferred free tissue.
11. Khoo CTK, Bailey BN. The behavior of free muscle and musculocutaneous aps after early
loss of axial blood supply. Br J Plast Surg 35:43-46, 1982.
12. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free aps:
A 10-year experience with 304 consecutive cases. J Trauma 29:1086-1094, 1989.
A retrospective review of 304 consecutive microvascular free aps to the lower extremity was done to
identify the patterns of usage, results, and problems.The most common indication (91%) was for the
replacement of extensive tissue loss caused by motor-vehicle injuries. Most of the defects were below
the mid-tibia (73%).The associated compound fractures were predominantly gradable as Gustilo
2055
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction

2056
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
type IIIb and IIIc.The latissimus dorsi, the rectus abdominus, and the scapular skin were the aps used
most commonly for coverage (77%).The overall ap failure rate was 8%, compared with 3% for
their series of non–lower extremity cases, and 0% for the nontraumatic lower extremity cases.The mag-
nitude of the traumatic insult was the most signi cant factor associated with anastomotic failure.The
rate of anastomotic thrombosis doubled in the presence of vascular trauma, increased threefold in the
presence of larger bony defects, and increased vefold when vein grafts were needed. Experience was
important in reducing the complications and improving the results. Fourteen patients (6%) underwent
an amputation within the rst 3 months, ten of them because of ap failure. Of 85 patients followed
up for over 1 year, 91% had recovered good to excellent leg function.The ability to add healthy and
well vascularized tissue to the traumatized limb is critical for the achievement of (1) early de nitive
wound healing and restoration of function, (2) salvage of many impending amputations, (3) better
prosthetic stump reconstructions (4) better aesthetic results.
13. Gordon L, Chiu EJ.Treatment of infected nonunions and segmental defects of the tibia with
staged microvascular muscle transplantation and bone grafting. J Bone Joint Surg Am 70:377-
386, 1988.
14. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting of high-energy tib-
ial fractures. Clin Orthop 240:21-41, 1989.
15. Ger R . Muscle transposition for treatment and prevention of chronic posttraumatic os-
teomyelitis of the tibia. J Bone Joint Surg Am 59:784-791, 1977.
16. Chang N, Mathes JS. Comparison of the effect of bacterial inoculation in musculocutaneous
and random-pattern aps. Plast Reconstr Surg 70:1-10, 1982.
17. Francel TJ,Vander Kolk CA, Hopper JE, et al. Microvascular soft tissue transplantation for re-
construction of acute open tibial fractures:Timing of coverage and long-term functional re-
sults. Plast Reconstr Surg 89:478-487, 1992.
18. Weiland AJ, Daniel RK. Microvascular anastomosis for bone grafts in the treatment of massive
defects in bone. J Bone Joint Surg Am 61:98-104, 1979.
19. Minami A, Kimura T, Matsumoto O, et al. Fracture through united vascularized bone grafts. J
Reconstr Microsurg 9:227-232, 1993.
20. Coleman JJ III. Long-term evaluation of muscle and musculocutaneous aps. In Mathes SJ, Na-
hai F, eds. Clinical Applications for Muscle and Musculocutaneous Flaps. St Louis: Mosby,
1982.
21. Godina M. Early microsurgical reconstruction of complex trauma to the extremities. Plast Re-
constr Surg 78:285-292, 1986.
22. Millican PG, Poole MD. Peripheral neovascularization of muscle and musculocutaneous aps.
Br J Plast Surg 38:369-374, 1985.

2057
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
1. Timing of secondary tendon transfer in the patient with an injured upper ex-
tremity who has undergone reoperative surgery depends on which of the fol-
lowing?
a. Solid union of the underlying bony fractures
b. Maximized passive range of joint motion
c. Tissue equilibrium
d. All of the above
2. The preferred donor musculotendinous units for reconstruction of the injured
extensor pollicis longus include:
a. Flexor carpi radialis longus
b. Abductor pollicis longus
c. Extensor indicis proprius
d. Flexor digitorum sublimis to ring nger
3. Fasciocutaneous aps that may help to achieve aesthetically superior contouring
and color outcomes in the extremities include all of the following except:
a. Groin ap
b. Parascapular ap
c. Anterolateral thigh ap
d. Rectus abdominis myocutaneous ap
4. The preferred method to approach an iliac crest bone graft procedure beneath
a previously placed ap includes which of the following?
a. Incision through the midbody of the ap
b. Approach at an anatomically separate location
c. Elevate the ap along the previous inset plane
d. Approach in the most convenient fashion
R EVIEW QUESTIONS

(Trang không có chữ)

P a r t V II
IN CLOSING

(Trang không có chữ)

2061
The ancient Greeks built the Acropolis with the intention that it would endure
for eternity. A similar optimism motivates most plastic surgeons in their operative
attempts to preserve and restore the human form. Just as monuments are subject to
natural and manmade assaults, however, so is our surgical artistry susceptible to the
ravages of time, disease, and biologic processes.Thus reoperative plastic surgery be-
comes a practical necessity as we use the newest technology and most advanced
surgical techniques in our efforts to correct complications, re ne results, and reverse
the stigmata of aging. In a word, reoperative plastic surgery is an inevitability of
our practices.
Reoperative plastic surgery continues to evolve. Each time one operates, something
new is learned. Each secondary procedure offers the potential for devising new so-
lutions to old problems and enhancing one’s appreciation of how scarred tissue
planes respond to traction and tension. Innovation and technology further in uence
this learning process and contribute to rede ning our expectations for the nal re-
sult. As we learn from these experiences, we learn to avoid unplanned reoperations
and cut down on the number of stages necessary to achieve optimal results.
In the training and education of plastic surgeons, there comes a time when the sur-
geon makes the transition from simply performing the memorized steps of an op-
eration to actually “seeing” what the tissues are doing in response to their mobiliza-
tion and movement. Like the chess master who is able to “see” the result of many
In Closing
James C. Grotting
C ha pter 5 1
Desire is the key to motivation, but it’s determination and commitment
to an unrelenting pursuit of your goal—a commitment to excellence—
that will enable you to attain the success you seek.
Mario Andretti

2062
PART VII
IN CLOSING
sequential moves which might be made by his opponent, the surgeon learns the
consequences of his or her “controlled tissue injury” and how it is likely to produce
a certain result. It is at that moment when the young surgeon goes from technician
to sculptor, controlling the outcome of an operation with much greater predictabil-
ity. Coupled with an ongoing critical review of his or her own postoperative results,
the plastic surgeon is now ready for a lifelong pursuit of excellence and in this way,
to reduce the incidence of unplanned reoperations.
I recently saw this patient for a follow-up visit. She had suffered a signi cant tissue
loss in her upper lip as a result of a dog bite. I tried to repair the wound with a ro-
tation ap of upper lip skin to restore the white roll and an advancement of the ver-
milion for restoration of the red lip. I explained to her that she would almost cer-
tainly require a reoperation in the future for improvement of contours or scars.
However, at her 6-month visit, remarkably, the result appeared better than I would
have anticipated. Even with the experience gained by years of practice and editing
this book, I continue to be astonished by the abilities of the human body to heal it-
self. . . if we can just help get it started along the right path!
Technologic improvements and new ideas have simpli ed certain secondary proce-
dures and have made others possible. Such advances as endoscopic instrumentation
and xation techniques, laser and radiofrequency technology, distraction osteoge-
nesis, bone and tissue substitutes, and nonsurgical approaches for facial rejuvenation,
including Botox and llers, continue to have an impact on our reoperative deci-
sion-making. Previously staged procedures can now be accomplished in a single
stage. Deformities previously correctable only through open surgery can now be
improved nonsurgically, with less risk and downtime.

As our understanding and appreciation of these new technologies deepen, the ap-
plications continue to evolve, and we are challenged as to how to best use these new
tools. In light of the changes that are affecting health care today, sound clinical judg-
ment is a skill as essential as technical expertise.
One of the ongoing challenges for the reoperative surgeon is de ning the endpoint
for surgical intervention.When is the result considered nal and unimprovable? Can
we be satis ed with an exceptionally well-contoured breast reconstruction that re-
mains insensate, or will nerve grafts performed at the time of reconstruction or in a
secondary procedure achieve a more perfect reconstruction? In the case of mandibu-
lar reconstruction, is restored contour suf cient, or is dental restoration needed to
enable normal mastication?
Health care reform has significant implications for reconstructive and aesthetic
plastic surgery. Global fee policies by insurance carriers place an added burden on
patients and surgeons as we try to accomplish as much as possible in one opera-
tion, since a subsequent procedure may not be reimbursed, regardless of whether
the surgeon and patient believe the surgery is necessary. Thus the nal result for
the patient may be determined by the policies instituted by managed care groups
or insurance companies rather than by the limits of the reoperative plastic sur-
geon’s creativity.
This book represents a collection of thoughts and techniques in evolution. Often
the person who learns the most from writing scienti c material is the author him-
self;one of the bene ts of having edited this book is what I have learned from each
of the contributors. My patients have been the benefactors of the information and
techniques garnered from the contributors of both editions of this book. It is my
hope that Reoperative Aesthetic & Reconstructive Plastic Surgery will stimulate readers to
re ect on the ways they have solved particular operative problems, to develop means
of minimizing the need for reoperations and increasing the safety and predictabil-
ity of primary procedures, and to communicate their innovations through the lit-
erature. With carefully documented outcome studies, we can in uence managed
care decisions regarding the quality of treatment for our patients. By educating one
another, we can vitalize and elevate the discussion of solutions to surgical prob-
lems that we all commonly encounter.
2063
Chapter 51
In Closing

(Trang không có chữ)

Table, p. 102
From Shiffman, MA.Warning about herbals in plastic
and cosmetic surgery. Plast Reconstr Surg 108:2180-
2181, 2001. (Courtesy Melvin A. Shiffman, MD.)
Figure, p. 163
Courtesy T.A. Gillian, MD.
Figures, p. 220
From Gilles H, Millard DR.The Principles and Art of
Plastic Surgery. Boston: Little Brown, 1957.
Figures, p. 221
From Rees TD,Wood-Smith D. Cosmetic Facial Surgery.
Philadelphia:WB Saunders, 1973.
Figure, p. 229
Courtesy F. Barton, MD.
Figures, p. 232 (bottom)
Cadaver study. Courtesy J.E. Pessa, MD.
Figure, p. 241
Courtesy Alfonso Barrera, MD.
Figure, pp. 263, 268, 269
From Stuzin JM, Baker TJ, Gordon HL.The relationship
of the super cial and depp facial fascias: Relevance to
rhytidectomy and aging. Plast Reconstr Surg 89:441-449,
1992.
Figure, p. 313
Courtesy A. von Ristow, MD.
Figure, p. 324
From Terzis JK, Daigle JP. Facial nerve reconstruction. In
Granick M, Hanna D, eds. Management of Salivary Gland
Lesions. Baltimore:Williams & Wilkins, 1992, p 251.
Box, p. 458
From Carraway JH, Mellow GC.The prevention and
treatment of lower lid ectropion following blepharoplasty.
Plast Reconstr Surg 85:971-981, 1990.
Figure, p. 753
From Walton RL, Burget GC, Beahm EK. Microsurgical
reconstruction of the nasal lining. Plast Reconstr Surg
115:1813-1829, 2005.
Figures, pp. 838-839
From Kohout MP, Hansen M, Pribaz JJ and Mulliken
JB. Arteriovenous malformations of the head and neck:
Natural history and management. Plast Reconstr Surg
102:643-654, 1998.
Figures, pp. 847-852
From Pribaz JJ, Morris DJ, Mulliken JB.Three-dimen-
sional folded free ap reconstruction of complex facial
defects using intraoperative modeling. Plast Reconstr
Surg 93:285-293, 1994.
Figures, pp. 904, 910, 918, 927, 931, 965, 976, 977
From Manson PN, Clark N, Robertson B, et al. Subunit
principles in midface fractures:The importance of sagittal
buttresses, soft tissue reductions and sequencing treat-
ment of segmental fractures. Plast Reconstr Surg 103:
1287-1306, 1999.
Figures, p. 934 (top)
From Crawley W. Cranioplasty. In Manson PN, ed. Prob-
lems in Craniofacial Surgery. Philadelphia: JB Lippincott,
1990, p 458.
Figure, p. 944
From Markowitz BL, Manson PN, Sargent L, et al.
Management of the medial canthal tendon in nasoeth-
moid orbital fractures:The importance of the central
fragment in treatment and classi cation. Plast Reconstr
Surg 87:843-853, 1991.
C1
C r ed i t s

C2
Credits
Figure, p. 981
From Crawley W, Azman P, Clark C, et al.The edentu-
lous LeFort fracture. J Craniofac Surg 8:298-308, 1997.
Figure, p. 996
From Clark N, Birely B, Manson PN, et al. High-energy
ballistic and avulsive facial injuries: Classi cation, patterns,
and an algorithm for primary reconstruction. Plast
Reconstr Surg 98:583-601, 1996.
Figure, p. 1087
From Riski JE, Ruff GL, Georgiade GS, et al. Evaluation
of failed sphincter pharyngoplasties. Ann Plast Surg 28:
545, 1992.
Figures, p. 1117
From Wolfe SA. Correction of a lower eyelid deformity
caused by multiple extrusions of alloplasticorbital wall
implants. Plast Reconstr Surg 68:429-432, 1981.
Figures, p. 1123
From Wolfe SA, Berkowitz S. Plastic Surgery of the
Facial Skeleton. Boston: Little Brown, 1989.
Figures, pp. 1450, 1451, 1457
From Grotting JC. Immediate breast reconstruction using
free TRAM ap. Clin Plast Surg 21:207-221, 1994.
Figures, p. 1467
From Grotting JC.The TRAM ap. In Hartrampf CR Jr,
ed. Hartrampf’s Breast Reconstruction With Living
Tissue. New York: Raven, 1991.
Figures, p. 1471
From Grotting JC. Breast reconstruction with free tissue
transfer. In Cohen M, ed. Mastery of Plast Reconstr Surg.
Boston: Little Brown, 1994.
Figure, p. 1473
From Core GB, Grotting JC. Peripheral nerve injury in
the free TRAM procedure. Perspect Plastic Surg 7:49-57,
1993.
Figures, p. 1568
From Stahl RS, Sando WC. Reconstruction of defects
of thorax and spine. In Jurkiewicz MJ, Krizek TJ, Mathes
ST, et al, eds. Plastic Surgery: Principles and Practice.
St Louis: Mosby, 1990; with permission from Elsevier.
Figures, p. 1583
From Stahl RS. Seyfer AE. Chest wall reconstruction. In
Russell RC, ed. Plastic Surgery Educational Foundation
Instructional Courses, vol 3. St Louis: Mosby, 1990.
Figure, p. 1638
Courtesy Oswaldo Saldanha, MD.
Figures, p. 1754
From Stoppa R. Advances in the care of large incisional
hernias. Hospimedica 10:43, 1992.
Figures, p. 1805
Courtesy R. Read, MD.
Figures, pp. 1838, 1846, 1847
From Yamamoto Y, Kunihiko N,Yoshihisa S, et al.
Reconstruction of recurrent pressure sores using free
aps. J Reconstr Microsurg 8:433-436, 1992. Reprinted
by permission.
Figure, p. 1882
Courtesy Christine Moran, MS, PT, CHT.
Figures, pp. 1968, 1969, 1971, 1976-1977, 1980-1981
From Mlakar JM, Dougherty W. Reconstruction of the
burned hand. In Herndon D, ed.Total Burn Care, 2nd
ed. Philadelphia:WB Saunders, 2002.
Figure, p. 1986
From Mackinnon SE, Dellon AL. Surgery of the Periph-
eral Nerve. New York:Thieme, 1988, p 21.
Box, p. 1989
From Dellon AL.Techniques for successful management
of ulnar nerve entrapment at the elbow. Neurosurg Clin
North Am 2:57-73, 1991.

Chapter 1
1.
b
2.
e
3.
d
4.
c
5.
e
Chapter 2
1.
a
2.
e
3.
d
4.
a
5.
e
Chapter 3
1.
d
2.
a
3.
a
4.
b
5.
d
6.
d
7.
c
8.
c
Chapter 4
No review
questions for
this chapter.
Chapter 5
1.
c
2.
d
3.
e
4.
c
5.
d
Chapter 6
1.
a
2.
e
3.
e
4.
c
5.
a
Chapter 7
1.
b
2.
c
3.
e
4.
d
5.
d
Chapter 8
1.
d
2.
e
3.
e
4.
e
5.
a
Chapter 9
1.
d
2.
c
3.
b
4.
d
5.
a
Chapter 10
1.
d
2.
d
3.
b
4.
c
5.
d
6.
d
7.
b
8.
c
9.
a
Chapter 11
1.
c
2.
c
3.
d
4.
b
5.
d
Chapter 12
1.
b
2.
c
3.
d
4.
d
5.
a
6.
e
Chapter 13
1.
d
2.
e
3.
e
4.
d
5.
d
Chapter 14
1.
d
2.
e
3.
c
Chapter 15
1.
d
2.
e
3.
d
4.
e
5.
c
A1
Chapter 16
1.
c
2.
e
3.
e
4.
c
5.
d
Chapter 17
1.
b
2.
c
3.
c
4.
b
5.
a
Chapter 18
1.
e
2.
a
3.
c
4.
d
5.
e
Chapter 19
1.
c
2.
e
3.
a
4.
d
5.
d
Chapter 20
1.
b
2.
c
3.
e
4.
c
5.
d
Chapter 21
1.
c
2.
b
3.
e
4.
d
5.
a
Chapter 22
1.
b
2.
b
3.
a
4.
e
5.
a
Chapter 23
1.
c
2.
b
3.
c
4.
b, c, d
5.
b, c
Chapter 24
1.
e
2.
b
3.
e
4.
d
5.
b, c, d
Chapter 25
1.
c
2.
b
3.
d
4.
a
5.
b
A n sw er K ey
to Review Questions

A2
Answer Key to Review Questions
Chapter 30
1.
a, b, d
2.
f
3.
b, c, e
4.
b
5.
a
Chapter 31
1.
a
2.
b
3.
e
4.
b
5.
d
6.
d
7.
d
8.
c
Chapter 32
1.
d
2.
b
3.
e
4.
c
5.
e
Chapter 33
1.
c
2.
d
3.
d
4.
c
5.
e
Chapter 34
1.
b
2.
c
3.
e
4.
e
5.
c
Chapter 26
1.
c
2.
a
3.
c
4.
b
5.
d
Chapter 27
1.
b
2.
b
3.
b
4.
d
5.
d
Chapter 28
1. b
2. c
3. d
4. b
5. b
6. a
7. e
8. b
9 e
10. d
11. b
12. b
13. d
14. d
15. d
16. d
Chapter 29
1.
d
2.
a
3.
d
4.
a
5
d
Chapter 35
1.
e
2.
a
3.
d
4.
c
5.
c
Chapter 36
1.
c
2.
c
3.
b
4.
b
5.
d
Chapter 37
1.
d
2.
c
3.
c
4.
e
5.
c
Chapter 38
1.
d
2.
d
3.
d
4.
d
5.
e
Chapter 39
1.
c
2.
a
3.
b
4.
c
5.
c
Chapter 40
1.
b
2.
c
3.
b
4.
b
5.
d
Chapter 41
1.
d
2.
d
3.
a
4.
d
5.
b
Chapter 42
1.
d
2.
b
3.
c
4.
d
5.
b
Chapter 43
1.
d
2.
c
3.
d
4.
d
5.
e
Chapter 44
1.
c
2.
b
3.
c
4.
d
5.
d
Chapter 45
1.
c
2.
d
3.
d
4.
a
5.
d
Chapter 46
1.
d
2.
a
3.
b
4.
d
5.
e
Chapter 47
1.
b
2.
a
3.
d
4.
e
5.
d
Chapter 48
1.
c
2.
a
3.
c
4.
a
5.
e
Chapter 49
1.
b
2.
a
3.
e
4.
b
5.
b
Chapter 50
1.
d
2.
c
3.
d
4.
c
Chapter 51
No review
questions for
this chapter.

A
Abbé ap, cleft lip and cleft lip nasal deformity
and, 1037-1040
Abdomen, lower,TRAM ap eventration in, 1817
Abdominal compartment syndrome (ACS), reop-
erative surgery of abdominal wall and, 1770
Abdominal contouring
bulging epigastrium following, 1656-1657
bulging anks following, 1656-1657
bulging hypogastrium following, 1656-1657
bulging periumbilicus following, 1656-1657
fat deposits following, 1657-1664
incorrect placement of umbilicus following,
1667-1669
primary operative approaches to, 1653-1669
problems following, 1655-1669
scar malposition following, 1665-1667
scars following, 1657-1664
skin laxity following, 1657-1664
umbilical malposition following, 1657-1664
Abdominal dehiscence, lytic phase of wound heal-
ing and, 30
Abdominal ap, thick, disparity between line of
closure and, 1728-1729
Abdominal ap necrosis, reoperation following free
ap breast reconstruction and, 1426-1427
Abdominal wall
anatomy of, 1742-1748
classi cation of defects of, 1749-1752
defects of, management protocols for, 1770-
1799
depth of injury to, 1751
location of defect in, 1752
lymphatics of, 1747
musculofascial layers of, 1744-1745
nerve supply of, 1747
phase of injury to, 1749-1750
reconstruction of
acute phase of, 1771-1781, 1799-1801, 1802,
1803
autologous methods of suturing in, 1759-
1760
autologous prosthetic materials for, 1757-
1758
autologous tissue aps, 1760-1761
case studies in, 1799-1814
chronic phase of, 1791-1799, 1801, 1805,
1806, 1807-1809, 1810-1812, 1813-1814
common problems in, 1815-1817
complications of, 1815
expanded polytetra uoroethylene for, 1755
aps in, 1761-1764
management of, 1766-1768
Mersilene for, 1756
nonautologous prosthetic materials for, 1753-
1757
operative planning and, 1769-1770
Prolene mesh for, 1753-1755
prosthetic materials for, 1752-1758
relaxing incisions in, 1759-1760
subacute phase of, 1781-1791, 1804
sutures used in, 1759-1761
tissue expansion in, 1766
tools for, 1752-1765
unanswered problems about, 1817-1818
use of negative pressure wound therapy in,
1765-1766
reoperative surgery of, 1741
skin of, 1743-1744
subcutaneous tissue of, 1743-1744
tools for reconstruction of, 1752-1765
traumatic loss of, from gunshot, 1817
vascular supply of, 1746-1747
wound status of, 1751
Abdominal wall contouring, breast reconstruction
with pedicled aps and, 1386
Abdominal wall defects
available tissue and, 1750
classi cation of, 1749-1752
depth of injury and, 1751
management protocols for, 1770-1799
phase of injury in, 1749-1750
wound status and, 1751
Abdominal wall reconstruction
prosthetic materials commonly used in, 1753
use of negative pressure wound therapy in,
1765-1766
Abdominoplasty
conventional, reoperation after liposuction and
body contour surgery and, 1640, 1657,
1665
and ankplasty, combined, 1674-1675
after liposuction and body contour surgery,
1672, 1692, 1694
psychological aspects of, 59-60
seroma following, 96, 1651-1653
traditional, reoperation after liposuction and
body contour surgery and, 1661
Ablative modalities in management of abnormal
scarring, 135-136
Abrasion, corneal
reoperative blepharoplasty and, 450
secondary ptosis correction and, 516
ACE-27; see Adult Comorbidity Evaluation-27
index
Acetone, scar modi cation and, 127
Acidic broblast growth factor (a-FGF), bropro-
liferative phase of wound healing and, 29
Acne, soft tissue llers and, 127
ACNT; see Anterior cutaneous nerve of thigh
Acquired auricular defects, major, treatment of,
787-788
Actinomycosis, reoperative plastic surgery and, 20
Active prosthetic tendon implants, exor tendon
repair and staged grafting and, 1927
Acute wound dehiscence, reoperative surgery of
abdominal wall and, 1815
Adenosine 5 -diphosphate (ADP), in ammatory
phase of wound healing and, 28
Adipose tissue, subcutaneous, reoperative liposuc-
tion and, 1607
Adjunctive techniques
to improve blepharoplasty result, 473-475
to improve face-lift result, 347-375
ADP; see Adenosine 5 -diphosphate
Adult Comorbidity Evaluation-27 index (ACE-
27), 832
Aeromonas hydrophila, leeches and, 203
Aesthetic considerations
facial reanimation and, 876
failed, in implant breast reconstruction, 1352-
1359
in midface area, 550-567
patient seeking secondary face lift and, 278-281
reoperative breast surgery after reduction
mammaplasty and mastopexy and, 1214
reoperative liposuction and, 1602-1606
secondary nipple-areola reconstruction and,
1405-1406
secondary rhinoplasty and, 598-605
in upper lid blepharoplasty, 577
Aesthetic deformities, iatrogenic, of lower eyelid
and cheek, 403-406
Aesthetic operative strategy, balancing, with goals
and risks, nasal reconstruction and,
707-708
Aesthetic rhinoplasty
in aging patient, 364-366
secondary, re-creation of alar cartilages in, 729-
735
Aesthetic surgery, facial, adjunctive procedures to
improve results in, 377-401
a-FGF; see Acidic broblast growth factor
A-frame deformity, upper lid crease and, 592
Aging
anatomic changes occurring with, 268-269
and augmented breast, treatment of, 1301-1304
facial, analysis of, 379
perioral, 396
I1
I n d ex

I2
Index
Aging—cont’d
reoperative plastic surgery and, 14
revisional fat grafting of cheek and lower eyelid
and, 405-406
Airway obstruction, postoperative, secondary cleft
palate surgery and, 1054
Alar bases, aring of, reconstruction of burned face
and neck and, 893
Alar cartilages, re-creation of, in secondary aes-
thetic rhinoplasty, 729-735
Alar cinch stitch technique, 350
Alar crease, reoperative surgery for nasal recon-
struction and, 712-713
Alar groove, reoperative surgery for nasal recon-
struction and, 712-719
Alar pinching, secondary rhinoplasty and, 666-671
AlloDerm, 1072-1073
reoperative surgery of abdominal wall and,
1757-1758
soft tissue llers and, 127
Alloplastic failure, reoperative craniomaxillofacial
surgery with emphasis on, 1113
Alloplastic implants, use of, for lower lid spacer
support mechanism, 469-472
Alopecia, use of endoscopy in reoperative brow-
lifting and, 343
Alpha-hydroxy acid
psychological considerations and, 61
scar modi cation and, 127
Altered anatomic relationships in reoperative plas-
tic surgery, 23
Altered tissue characteristics in reoperative plastic
surgery, 24-25
Alternative ap vessels, ap circulation impairment
and, 209
Alternative recipient vessels, ap circulation im-
pairment and, 206-208
Aluminum oxide crystals, dermabrasion and, 125
Alveolar stulas, 1069-1070
Alveolar grafting, cleft lip and cleft lip nasal defor-
mity and, 1040-1042
Alveolar region, stulas in, 1069-1070
American Society of Plastic and Reconstructive
Surgeons (ASPRS), 223
American Society of Plastic Surgeons (ASPS), 55
Amputation, secondary surgery after digit replanta-
tion and, 1954
Amputation stump pain, reoperative peripheral
nerve surgery and, 2000
Anastomosis
end-to-side, cross-facial nerve grafting with,
862, 867-869
revision of, in detection of ap circulation im-
pairment, 205-206
Anatomic considerations
aging and, reoperative rhytidectomy and, 268-
269
altered, in reoperative plastic surgery, 23
breast reconstruction with pedicled aps and,
1371-1374
reoperative breast surgery after reduction
mammaplasty and mastopexy and, 1199-
1200
reoperative brow-lifting and, 334-335
reoperative facial fracture repair and, 906-911
reoperative surgery of chest wall and, 1528
vascular, reoperative forehead lift and, 311-313
Anatomic examination, topographic, secondary
rhinoplasty and, 596-598
Anatomy
reoperative rhytidectomy and, 259-270
reoperative surgery after breast augmentation
and, 1264-1269
reoperative surgery of abdominal wall and,
1742-1748
use of endoscopy in reoperative brow-lifting
and, 339-343
Anchor blepharoplasty, secondary ptosis correction
and, 521
Anchoring
canthal; see Canthal anchoring
lateral canthal; see Lateral canthal anchoring
Anemia, wound healing and, 107
Anesthesia
face-lift techniques and, 232-233
for lower eyelid and cheek, restoration of
fullness to lower eyelid and cheek and,
416-428
Angiotensin, broproliferative phase of wound
healing and, 29
Angle fractures, reoperative facial fracture repair
and, 988-990
Angry patient, 44
Anterior axillary fold, absence of, breast recon-
struction with pedicled aps and, 1398-
1399
Anterior cutaneous nerve of thigh (ACNT), reop-
erative peripheral nerve surgery and, 2000
Anterior iliac spine (ASIS), body contouring in
massive-weight-loss patient and, 1728-1729
Anterior SMAS, suspension of, to fascia above zy-
gomatic arch, 225-231
Anteroposterior dystopia, reoperative craniomax-
illofacial surgery and, 1160
Antiaging procedures
minimally invasive, 60-61
surgical, psychological aspects of, 60
Anticoagulation
in detection of ap circulation impairment, 202
hematoma and, 92
Antitension lines (ATLs), scar revision and, 119
Antithrombin III (AT III), coagulation and, 99
Apert’s syndrome, reoperative craniomaxillofacial
surgery and, 1162-1165
Aperture direction following fat grafting to orbital
region, 434-435
Aponeurosis plication and reinsertion, secondary
ptosis correction and, 521-522
Aponeurosis repair, secondary ptosis correction
and, 520
Aponeurotic safety switch, differences between
nasal and temporal upper lid and, 580
Areolar tattooing, 9, 1462
Arms, complications in, after body contouring
in massive-weight-loss patient and, 1734-
1735
Arteries, use of type III cannula near, following fat
grafting to orbital region, 436
Arteriovenous malformation (AVM)
combining distant and local tissues and, 847-853
reoperative issues following ap reconstruction
in head and, 838-842
Arthritis, rheumatoid; see Rheumatoid arthritis
Arthrodesis, secondary surgery after digit replanta-
tion and, 1951
Arthroplasty
distal interphalangeal joint, 1891
knee, reoperative peripheral nerve surgery and,
1999
metacarpophalangeal joint, 1882-1888
of proximal interphalangeal joint, 1888-1891
reoperative hand surgery and, 1881-1891
revision, 1886-1887
secondary surgery after digit replantation and,
1951
Swanson, 1884-1886
Arthroscopic knee surgery, reoperative peripheral
nerve surgery and, 1999
Articular branch of common peroneal nerve, re-
operative peripheral nerve surgery and,
2000
Articulations, compensatory, velopharyngeal insuf-
ciency and, 1062-1063
ASIS; see Anterior iliac spine
Aspirin
disorders of clotting factors and, 101
hematoma and, 92
platelet disorders and, 100
wound healing and, 106
ASPRS; see American Society of Plastic and Re-
constructive Surgeons
ASPS; see American Society of Plastic Surgeons
Asymmetry
breast mound and, after reduction mammaplasty
and mastopexy and, 1214-1224
breast reconstruction with pedicled aps and,
1392, 1394-1396
in reoperative plastic surgery, 26
TRAM ap and, 1375-1376
AT III; see Antithrombin III
ATLs; see Antitension lines
Atrophy, hemifacial, reoperative craniomaxillofacial
surgery and, 1168-1169
Augmentation
breast; see Breast augmentation
with fat, imaging considerations in, 1486
Augmented auricular framework, second-stage
placement of, in ear reconstruction, 784-
789
Auricle
dystopic, reconstruction of, in ear reconstruc-
tion, 778-781
reoperative surgery of, 788-789
Auricular defects, major acquired, treatment of,
787-788
Auricular dystopia
correction of skeletal hypoplasia in treatment of,
785-787
staged sequential procedures for ear reconstruc-
tion and, 762
temporoparietal fascial ap in reconstruction of,
784

I3
Index
Auricular framework, augmented, second-stage
placement of, in ear reconstruction, 784-
789
Auricular hematomas, 94
Auricular reconstruction and distraction osteogen-
esis, integration of, 787
Autoaugmentation using reverse abdominoplasty,
1308-1310
Autogenous conversion, breast implants and, 1354-
1357
Autologous fat injections into lower lid, complica-
tions of, 566-567
Autologous fat transfer, facial aesthetic surgery and,
380-381
Autologous methods, reconstruction of abdominal
wall and, 1759-1760
Autologous prosthetic materials, reconstruction of
abdominal wall and, 1753, 1757-1758
Autologous tissue aps, reconstruction of abdomi-
nal wall and, 1760-1761
AVM; see Arteriovenous malformation
Axillary fold, anterior, absence of, breast recon-
struction with pedicled aps and, 1398-
1399
Axillary hollowness, breast reconstruction with
pedicled aps and, 1400-1402
B
“Babysitter” technique, facial reanimation and,
863
Baker-Goodman formula, scar modi cation and,
127
BAPN; see Beta-aminopropionitrile
Bariatric surgery, psychological considerations and,
59-60
Baroudi’s technique, conventional, 1640
Basal cell carcinoma (BCC), 801-828
patient evaluation and, 807-808
recurrent, 13
treatment modalities for, 808-809
Basic broblast growth factor (b-FGF), broprolif-
erative phase of wound healing and, 29
BCC; see Basal cell carcinoma
BDD; see Body dysmorphic disorder
Behavior in of ce of patient undergoing cosmetic
surgery, observing, 66
Bell’s palsy, secondary procedures in facial reanima-
tion and, 867, 868, 870
Beta-aminopropionitrile (BAPN), effect of, on col-
lagen, 106
b-FGF; see Basic broblast growth factor
Bichat’s fat pad, roof of, face-lift techniques and,
225-231
Bichat’s fat pocket, 225, 228, 234, 235
Bilateral cleft nose, 1045-1047
Bilateral deformity, cleft lip and cleft lip nasal de-
formity and, 1030
Bilateral ischial pressure sores, 1854-1856
Bilateral trochanteric pressure sores, 1854-1856
bi-Luer-Lok connector, fat aspiration and, 127
Biologic processes, continued, reoperative plastic
surgery and, 14-15
Bioprosthetics, reoperative surgery of abdominal
wall and, 1757-1758
Bleeding
disorders of, hematoma and, 92
platelet disorders and, 99
postoperative, secondary cleft palate surgery and,
1054
secondary ptosis correction and, 517
Bleomycin in management of abnormal scarring,
132
Blepharoplasty
anchor, secondary ptosis correction and, 521
lower lid
facial aesthetic surgery and, 386
reoperative, 481-512
psychological considerations and, 60
reoperative, 441-479
adjunctive techniques to improve blepharo-
plasty result and, 473-475
adjunctive techniques to improve result of,
473-475
complications and, 448-453
lower lid problems and, 457-469
patient evaluation and, 442-446
skin markings and incisions and, 447
timing of, 446-447
upper and lower lid problems and, 472-473
upper lid problems and, 453-457
use of alloplastic implants for lower lid spacer
support mechanism and, 469-472
secondary, secondary ptosis correction and, 522
transconjunctival lower, 482
upper lid; see Upper eyelid blepharoplasty
Blepharoptosis, secondary ptosis correction and,
524
Blood supply; seeVascular supply
Blunting of tragus, face-lift techniques and, 241
Body contouring
liposuction and, reoperation after; see Liposuc-
tion and body contouring surgery, reopera-
tion after
in massive-weight-loss patient, 1701-1740
reoperation after, 1635-1699
Body dysmorphic disorder (BDD), 45, 56, 57, 61-
62, 66
Body image, dissatisfaction with, body dysmorphic
disorder and, 63-64
Bone, nonvascularized graft complications and,
148-149
Bone grafting
cranial, nasal reconstruction using, 1175-1178
onlay, reoperative craniomaxillofacial surgery
and, 1175
secondary iliac crest, ap elevation for, 2031-
2038
secondary surgery after digit replantation and,
1946-1947
Bone healing, reoperative facial fracture repair and,
906-907
Bone loss, facial fractures with, 995-999
Bone transfer, vascularized, after soft tissue cover-
age, 2038-2044
Bony de ciency, cleft lip and cleft lip nasal defor-
mity and, 1040
Bony disproportion, cleft deformities and, 1048
Bony imbalance, recurrent pressure sores and, 1830
Bony reconstruction
reoperation following ap reconstruction in
head and, 835
reoperation of chest wall and, 1585-1586
Botox injections
facial aesthetic surgery and, 384
psychological considerations and, 60-61
reoperative hand surgery and, 1899, 1905
“Bottoming out,” recurrent ptosis and, 1228
Botulinum toxin, facial aesthetic surgery and,
384-386
Boutonnière deformity, 1977-1978
Bovine collagen
in management of abnormal scarring, 128
soft tissue llers and, 127
Bowel, organ transfers and, 169-170
Brachial plexus
muscle and musculocutaneous aps and, 155
reoperative peripheral nerve surgery and, 1988-
1989
Breast
aging and augmented, treatment of, 1301-1304
and chest wall, reoperative surgery of, 1195-
1198
complications after body contouring in massive-
weight-loss patient and, 1735-1736
hematomas and, 95
irradiated, reoperative breast surgery after reduc-
tion mammaplasty and mastopexy and,
1253-1254
plastic surgery of, imaging considerations in,
1481-1509
augmented breast and, 1483-1496
detection of breast cancer in cosmetically al-
tered breast and, 1504
lifted breast and, 1496-1499
preoperative imaging evaluation and, 1502-
1503
reconstructed breast and, 1500-1502
reduced breast and, 1496-1499
reoperative surgery of
after breast augmentation, 1261-1316
nishing touches after breast reconstruction
with pedicled aps and, 1365-1409
following free ap breast reconstruction,
1411-1480
following implant breast reconstruction,
1317-1364
imaging considerations in, 1481-1509
local recurrence after mastectomy with breast
reconstruction and, 1511-1524
after massive-weight-loss plastic surgery,
1720-1723
after reduction mammaplasty and mastopexy,
1197-1259
after weight loss, 1721
Breast adjustments, reoperation following implant
breast reconstruction and, 1343-1346
Breast asymmetry, breast reconstruction with pedi-
cled aps and, 1394-1396
Breast augmentation
hematomas and, 95
imaging considerations in, 1483-1496
psychological aspects of, 57-59

I4
Index
Breast augmentation—cont’d
psychological considerations and, 60
reoperative surgery after, 1261-1316
applied anatomy and, 1264-1269
capsular contracture and, 1278-1284
device failure and, 1285-1288
hematoma and, 1270-1271
hypertrophic scarring and, 1270
implant malposition and, 1273-1278
infection and, 1271-1272
patient evaluation and, 1262-1263
rates of, 1263
reoperative challenges and, 1305-1310
seroma and, 1270
silicone-associated problems and, 1288-1300
timing of, 1263-1264
treatment of aging and augmented breast and,
1301-1304
wound dehiscence and, 1272-1273
Breast cancer
detection of, in cosmetically altered breast, 1504
local recurrence of, after mastectomy and breast
reconstruction, 1511-1524
implant-reconstruction and, 1516-1517
methods for detection of, 1513-1516
myocutaneous ap reconstruction and, 1517
origins of, 1512-1513
prognosis after, 1521
risk factors for, 1512
treatment of, 1519-1521
occult, reoperative breast surgery after reduction
mammaplasty and mastopexy and, 1251-
1252
Breast ap, 198
Breast implant
adding additional soft tissue to, 1353-1354
altering size and shape of, 1353
early problems after, 1348-1351
failed aesthetics in, 1352-1359
imaging considerations in augmented breast and,
1486-1496
late problems after, 1351-1359
lateral displacement of, correction of, 1339-
1342
local recurrence of breast cancer in, 1516-1517
malposition of, reoperative surgery after breast
augmentation and, 1273-1278
psychological considerations and, 57-59
recurrence of breast cancer after reconstruction
with, 1519
relationship between suicide and, 58-59
reoperation following, 1317
rupture of
detection of, 1493-1496
imaging, considerations in augmented breast
and, 1490-1493
saline; see Saline breast implant
silicone gel– lled, failure of, 1286-1288
Breast mound problems
reoperation after reduction mammaplasty and
mastopexy and, 1214-1239
reoperation following free ap breast recon-
struction and, 1427-1452
Breast ptosis, reoperative plastic surgery and, 14
Breast reconstruction
detection of breast cancer in, 1504
free ap, reoperation following, 1411-1480
imaging considerations in augmented breast and,
1500-1502
implant, reoperation following, 1317-1364
early problems after, 1348-1351
late problems after, 1351-1359
staged breast reconstruction and, 1318-1347
local recurrence of breast cancer after, 1511-
1524
mastectomy and, local recurrence of breast can-
cer after, 1511-1524
with pedicled aps, 1365-1409
aesthetic possibilities and limitations of, 1405-
1406
anatomic considerations and, 1371-1374
nishing touches after, 1365-1409
inadequate central breast projection and, 1391
inframammary fold correction and, 1390
latissimus dorsi ap and, 1373-1374
patient evaluation and, 1367-1369
planning and, 1369-1371
postoperative care and, 1404-1405
reoperation after latissimus dorsi ap and,
1391-1402
reoperation after TRAM ap and, 1375-1391
secondary nipple-areola reconstruction and,
1403-1404
tissue excess and, 1383-1389
TRAM ap de ciency and, 1375-1382
TRAM ap revision and, 1371-1373
after reduction mammaplasty and mastopexy,
1197
staged, 1318
Breast reduction
hematomas and, 95
imaging considerations in, 1496-1499
insuf cient, breast mound and, 1235-1239
of medial canthal ligament using transnasal wire
placement, 944
Brow asymmetry, use of endoscopy in reoperative
brow-lifting and, 343
Brow irregularity, use of endoscopy in reoperative
brow-lifting and, 343
Brow lift, secondary, reoperative blepharoplasty
and, 475
Brow ptosis
recurrent, reoperative forehead lift and, 323
use of endoscopy in reoperative brow-lifting
and, 341-342
Brow region, facial aesthetic surgery and, 386-392
Brow treatment, complications in eyelid surgery
and, 581-582
Brow-lifting, reoperative, use of endoscopy in, 333
anatomic considerations and, 334-335
anatomic rationale and, 339-343
biplanar technique and, 338
standard endoscopic technique and, 336-337
subperiosteal dissection and, 339
surgical technique and, 335-339
Bruising problems, platelet disorders and, 99
Bulge repair, hernia and, breast reconstruction with
pedicled aps and, 1387-1389
Bulging epigastrium, abdominal contouring and,
1656-1657
Bulging anks, abdominal contouring and, 1656-
1657
Bulging hypogastrium, abdominal contouring and,
1656-1657
Bulging periumbilicus, abdominal contouring and,
1656-1657
Bupivacaine hydrochloride (Marcaine), secondary
rhinoplasty and, 617
Burn scar contractures, surgical treatment of, 1966,
1967
Burned face and neck, primary care and secondary
reconstruction of, 881
method of excision and grafting and, 882-885
secondary deformities and their reconstruction
and, 885
Burned hand, challenges to, 1965
Burns
affecting bones, upper extremity and, 1978
affecting joints, upper extremity and, 1978
affecting soft tissues, upper extremity and, 1978
hand, common sequelae of, 1966
reoperative plastic surgery and, 18-19
upper extremity, reoperative surgery after exci-
sion and grafting of, 1963
wound healing and, 107
Bursa, recurrent pressure sores and, 1832
Bursa pressure sores, recurrent olecranon, 1850-
1851
Buttock ptosis, reoperative liposuction and, 1621-
1625
Buttocks procedures, reoperation after liposuction
and body contour surgery and, 1675-1681
Buttress system analysis for edentulous maxillary
and mandible fractures, 981
Bzoch clinical test form, secondary cleft palate sur-
gery and, 1061
C
Cancer, breast; see Breast cancer
Cancer chemotherapeutic agents; see Chemothera-
peutic agents
Cancer patient, terminal, 48
Cannula
in ltration, restoration of fullness to lower eyelid
and cheek and, 419
type III, use of, near veins and arteries, following
fat grafting to orbital region, 436
Canthal anchoring
lateral; see Lateral canthal anchoring
lower lid complications and, 570-573
Canthal xation point, reoperative lower lid bleph-
aroplasty and, 490
Canthal injuries, medial, reoperative facial fracture
repair and, 940-945
Canthal malposition, orbital fractures and, 965-
968
Canthal reanchoring, lower lid complications and,
570-573
Canthal supraplacement, limits of, complications in
eyelid surgery and, 562
Canthal webs, medial, reconstruction of burned
face and neck and, 892-893

I5
Index
Canthopexy
versus canthoplasty, 554-555
lateral, 1175
medial, 1173-1174
Canthoplasty versus canthopexy, complications in
eyelid surgery and, 554-555
Capillary budding, broproliferative phase of
wound healing and, 29
Capsular contracture
after breast implant reconstruction, 1351
breast reconstruction with pedicled aps and,
1394-1396
causes of, 1278-1280
open capsulotomy for, 1281-1283
reoperative surgery after breast augmentation
and, 1278-1284
of saline implant with periareolar mastopexy
deformity, 1307-1308
treatment of, 1281-1284
Capsulectomy, total, silicone-associated problems
and, 1294-1300
Capsuloplasty, secondary surgery after digit replan-
tation and, 1950-1951
Capsulotomy
open, for capsular contracture, 1281-1283
reoperative surgery after excision and grafting of
upper extremity burns and, 1972
secondary surgery after digit replantation and,
1949-1950
total, for capsular contracture, 1284
Carbohydrates, wound healing and, 108
Carboxyhemoglobin (COHb)
effects of, on face-lift aps, 231
impaired wound healing and, 117
Carcinoma
basal cell; see Basal cell carcinoma
squamous cell; see Squamous cell carcinoma
Cardiothoracic procedures, alternative surgical
approaches for, 1543
Carpal boss syndrome, reoperative hand surgery
and, 1914-1915
Carpal tunnel decompression, reoperative periph-
eral nerve surgery and, 1992
Carpal tunnel syndrome, recurrent, 1992-1993
Cartilage
alar, re-creation of, in secondary aesthetic rhino-
plasty, 729-735
construction of framework of, in ear reconstruc-
tion, 764-765
de ciency of, with limited scarring, ear recon-
struction and, 789-792
de ciency of, with moderate and severe scar-
ring, ear reconstruction of, 792-794
nonvascularized graft complications and, 149-
150
Cartilage grafting
forcing contour with, under skin grafts, 726-
729
reoperative blepharoplasty and, 465-468
Cartilaginous nasal framework, early secondary
installation of, 736-745
Cauli ower ear, 94
Cellular proliferation, wound healing and, 115-116
Central breast projection, inadequate, 1391
Central fragment, oblique transnasal reduction of,
941-943
Centrifugation, restoration of fullness to lower eye-
lid and cheek and, 416, 417
Cheek
anesthesia for, 417-428
iatrogenic aesthetic deformities of, 403-406
and lower eyelid, revisional fat grafting of, 403-
439
correction of problems following fat grafting
to orbital region and, 433-436
evaluation and, 407-411
iatrogenic aesthetic deformities of, 403-406
restoration of fullness to, 412
treatment of, 407-411
reducing fullness of, face-lift result and, 373
restoration of fullness to, 412-432
two-dimensional hypertrophic scars on, 888-
889
Cheek defects, reconstruction after resection of
recurrent cutaneous malignancies of head
and neck and, 812-813
Chemical peels
facial aesthetic surgery and, 381-383
nonsurgical scar modi cation and, 126-127
reoperative blepharoplasty and, 473-475
Chemotherapeutic agents
impaired wound healing and, 117
wound healing and, 106
Chest wall
and breast, reoperative surgery of, 1195-1198
lateral deformities of, 1589-1591
reoperative surgery of, 1525-1597
anatomic considerations and, 1528
bony reconstruction and, 1585-1586
depression and protrusion deformities and,
1587-1589
empyema and, 1565-1566
stula and, 1566-1567
future challenges and, 1593
goals of, 1538-1539
indications for, 1562-1564
lateral chest wall deformities and, 1589-1591
patient evaluation and, 1529-1536
pectus carinatum and, 1587-1589
pectus excavatum and, 1587-1589
for pediatric patient, 1538
physiologic considerations and, 1528
planning and, 1536-1538
pleural space problems and, 1565
Poland’s syndrome and, 1589-1591
postoperative care and, 1591-1593
preoperative preparation for, 1541-1542,
1567-1570
soft tissue reconstruction and, 1586-1587
sternal wounds and, 1539-1561
timing of, 1528-1529
wound vacuum-assisted closure device and,
1562
Child; see Pediatric patient
Chin
attened, reconstruction of burned face and
neck and, 895-896
ptotic, face-lift result and, 359-363
Christmas disease, disorders of clotting factors
and, 100
Chronic pain
after breast implant reconstruction, 1352
reoperative surgery and, 47
Chronic postburn joint problems, upper extremity,
1972
Chronic regional pain syndrome (CRPS), reopera-
tive hand surgery and, 1875
Chronic wound, recurrent pressure sores and, 1832
Cigarette smoking; see Smoking
Clagett procedure, reoperative surgery of chest
wall, 1585
Clean wounds, reoperative surgery of abdominal
wall and, 1751
Cleft deformities, treatment for patient without,
1014-1016
Cleft lip and cleft lip nasal deformity, secondary
corrections for, 1013
bilateral deformity and, 1030
diagnostic tests in assessment of, 1018
unilateral deformity and, 1018-1030
Cleft lip nasal deformity, secondary corrections for,
1013
Cleft nose
bilateral, 1045-1047
unilateral, secondary correction of, 1024-1028
Cleft palate surgery, secondary, 1053-1112
early postoperative problems and, 1054
evaluation of speech and, 1056-1065
long-term problems and, 1054-1055
palatal stulas and, 1065-1073
physical management of velopharyngeal incom-
petence and, 1075
prosthetic management of velopharyngeal in-
competence and, 1075
residual velopharyngeal incompetence after
palate repair and, 1073-1075
surgical management of velopharyngeal incom-
petence and, 1075-1099
Closed-circuit anesthesia, face-lift techniques and,
232-233
Closed-system anesthesia, face-lift techniques and,
232-233
Clotting factors, disorders of, 100-104
CO 2 laser, nonsurgical scar modi cation and, 125-
126, 135
Coagulation
abnormalities of, 97-101
extrinsic pathway of, 98-99
in ammatory phase of wound healing and, 28
Coagulation cascade, liver disease and, 101
Coagulopathies, disorders of clotting factors and,
100
Cocaine nose, secondary rhinoplasty and, 619-
620
Coexistent ptosis, correction of, complications in
eyelid surgery and, 582
COHb; see Carboxyhemoglobin
Colchicine, wound healing and, 106
Cold intolerance, secondary surgery after digit re-
plantation and, 1954
Collagen formation in wound healing in reopera-
tive surgery, 29

I6
Index
Collagen-producing broblasts, collagen formation
and, 29
Color and hyperpigmentation mismatch, recon-
struction of burned face and neck and, 899
Columella, hanging, correction of, face-lift result
and, 365-366
Columella defect, repair of, microsurgical salvage
procedures and, 747-750
Columellar reconstruction, cleft lip and cleft lip
nasal deformity and, 1034-1036
Combined ankplasty and abdominoplasty, 1674-
1675
Combined mandibular fractures, reoperative facial
fracture repair and, 992-994
Combined procedures, reoperation after liposuc-
tion and body contour surgery and, 1681
Comminuted fractures, reoperative facial fracture
repair and, 990
Comminuted nasal fracture, failure to perceive,
950-951
Common peroneal nerve (CPN), reoperative pe-
ripheral nerve surgery and, 1999, 2000
Common secondary complications, 89-111
Communication
disorders of, clinical tests for, 1061
with reoperative patient, 38-41
Compensatory articulations, velopharyngeal insuf-
ciency and, 1062-1063
Compensatory procedures in patients with promi-
nent eyes, 563-567
Complement cascade, in ammatory phase of
wound healing and, 28
Complete ap loss, reoperation following free ap
breast reconstruction and, 1422-1424
Complex reconstruction, reoperation following
free ap breast reconstruction and, 1463-
1464
Complex thumb reconstruction, 1979-1982
Complications
associated with aps used in conjunction with
breast implants, 1348-1351
after body contouring in massive-weight-loss
patient, 1701
common secondary, 89
donor site, reoperation for, 147
early, following primary and secondary rhytidec-
tomy, 271
in eyelid surgery, reoperation and avoidance and
treatment of, 545
exor tendon repair and staged grafting and,
1919-1920, 1924-1925
ganglion excision and, 1914
in head and neck reconstruction, 831
metacarpophalangeal joint arthroplasty and,
1887-1888
possible, nancial aspects of, 42-44
proximal interphalangeal joint arthroplasty and,
1891
Raynaud syndrome and, 1909-1910
recurrent pressure sores and, 1827-1832
reoperative blepharoplasty and, 448-453
reoperative breast surgery after reduction
mammaplasty and mastopexy and, 1201-
1214
reoperative hand surgery and, 1879
reoperative lower lid blepharoplasty and, 496-
499
reoperative plastic surgery and, 16-17
reoperative surgery of abdominal wall and, 1815
secondary ptosis correction and, 516-520
Components separation method, reoperative sur-
gery of abdominal wall and, 1759-1760
Composix, reoperative surgery of abdominal wall
and, 1756-1757
Concomitant recurrent pressure sores, 1852-1856
Condylar fractures, reoperative facial fracture repair
and, 991-992
Congenital facial paralysis, secondary procedures in
facial reanimation and, 870-872
Consent, informed; see Informed consent
Consultant, use of, reoperation and, 79-80
Contaminated wounds, reoperative surgery of ab-
dominal wall and, 1751
Continued biologic processes, reoperative plastic
surgery and, 14-15
Contour, forcing, with cartilage grafts under skin
grafts, 726-729
Contour defects
breast mound and, 1224-1228
reoperative forehead lift and, 319
smaller, reoperation following free ap breast
reconstruction and, 1441-1449
Contour irregularities
correction of, reoperative liposuction and, 1617-
1618, 1619, 1626-1628
TRAM ap and, reoperation following free ap
breast reconstruction and, 1468
Contouring, body, in massive-weight-loss patient,
1701
Contracture
capsular; see Capsular contracture
correcting, primary care and secondary recon-
struction of burned face and neck and,
887
of donor site, breast reconstruction with pedi-
cled aps and, 1396-1398
neck, reconstruction of burned face and neck
and, 897
Copper
de ciency of, 117
wound healing and, 106
Corneal abrasion
reoperative blepharoplasty and, 450
secondary ptosis correction and, 516-517
Coronal incision, nasoethmoidal fracture reduction
and stabilization and, 942
Corrective osteotomy, secondary surgery after digit
replantation and, 1947
Corticosteroids
intralesional, 136
in management of abnormal scarring, 130-131
in treatment of keloids, 136
Cosmetic surgery, psychological considerations
and, 60
Cosmoderm in management of abnormal scarring,
128
Cosmoplast in management of abnormal scarring,
128
Costochondral grafts, reoperative craniomaxillofa-
cial surgery and, 1178-1179
Costochondritis after breast implant reconstruc-
tion, 1352
Coumadin; seeWarfarin
CPN; see Common peroneal nerve
Cranial bone grafts, nasal reconstruction using,
1175-1178
Cranial bone harvesting, secondary rhinoplasty and,
633
Cranial irregularity, correction of, 1170-1172
Craniomaxillofacial surgery, reoperative, 1139
correction of cranial irregularity and, 1170-1172
costochondral grafts and, 1178-1179
with emphasis on alloplastic failure, 1113
failed primary surgery and, 1151-1161
free tissue transfer and, 1180-1183
lateral canthopexy and, 1175
medial canthopexy and, 1173-1174
nasal reconstruction using cranial bone grafts
and, 1175-1178
onlay bone grafting and, 1175
radiologic studies and, 1141-1143
secondary procedures and, 1162-1169
skull base approaches for tumors and tumor re-
currences and, 1184-1190
staged procedures and, 1144-1150
techniques and, 1170-1183
upper lid ptosis and, 1179-1180
Cranioplasty, reoperative facial fracture repair and,
932-934
Craniosynostosis, reoperative craniomaxillofacial
surgery and, 1162
Cranium, nonvascularized graft complications and,
148-149
Creases, upper eyelid, sulcus abnormalities and,
592
Creation of alar groove, nasal reconstruction and,
712-719
Croissant expander, 190
Cross-facial nerve grafting
with end-to-side anastomosis, 862, 867-869
facial reanimation and, 861
Crouzon’s syndrome, craniosynostosis and, 1162
CRPS; see Chronic regional pain syndrome
Crura, long middle, secondary rhinoplasty and,
673-678
Cryoprecipitate, disorders of clotting factors and,
100
Cryosurgery in management of abnormal scarring,
135
Cubital syndrome, reoperative peripheral nerve
surgery and, 1989-1990
Cupid’s bow, destroyed, at upper lip with, 894-895
Curare, face-lift techniques and, 232-233
Cutaneous malignancies, recurrent, of head and
neck, surgery for, 801
Cutaneous nerves of thigh, reoperative peripheral
nerve surgery and, 2000
CV ap, secondary nipple-areola reconstruction
and, 1403
Cyclophosphamide, wound healing and, 106
Cysteine, wound healing and, 108
Cytokines, in ammation and, 115