The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1016
the vascularized bone does not completely cover the defect
but supports the soft tissue like the poles of a tent and pro­
tects the brain like a bicycle helmet. Because of this incom­
plete bony reconstruction, a secondary surgery, using split
calvarial bone grafts, to improve contour and fill in the gaps
is typically performed 3 to 6 months later (Fig. 54.17). We
have found complete osseointegration of the vascularized
bony construct with itself and surrounding native bone af­
ter secondary surgery (see Fig. 54.17b). In contrast, when
a previously infected or contaminated, nonacute wound is
approached, a “hybrid” cranioplasty, consisting of nonvas­
cularized (typically split calvarial) and vascularized bone,
can be safely performed in a single stage.7 In neither case of
infected or high-risk composite defects should alloplastic
materials be used in the acute setting50 (Video 54.3).
Exposed Alloplast
Typically, a complex scalp wound presents itself not as a
fresh defect, but one that has undergone multiple attempts
at reconstruction. Further complicating matters is the pen­
chant for surgeons to use alloplastic (customized, fabri­
cated) implants to reconstruct the cranial defect. This often
results in implant exposure when used in less-than-ideal
settings. The shortcomings of this approach to cranioplasty
are well established:
1. Bacteria may live quiescent in scars of wounds for
years.
2. No synthetic material to date has shown to osseointe­
grate and therefore it can serve as a nidus for infection.
3. As soft tissues contract, they tend to thin and put any
underlying foreign body at risk for exposure.
Because of these issues, alloplastic reconstruction in the
setting of hostile conditions has a success rate of only 40 to
50%.51 Specifically, when an alloplast is used in a previously
infected site, the reinfection rate is as high as 40%,51 neces­
sitating explantation. For these reasons, we advise prompt
Postoperative Complications
Acute versus Chronically Infected
Composite Scalp Defect
With a high-risk or hostile, infected, composite defect, the
timing of reconstruction is a critical factor in the success of
the revision surgery. This is somewhat controversial in the
literature, however; some authors have supported a delay
of 6 to 12 months when approaching infected wounds.45 A
prerequisite to safely closing any infected wound is to first
obtain bacteriologic balance, which is defined as fewer
than 105 organisms per gram of tissue of both soft tissue47
and bone.48 Typically in a well-vascularized scalp, this is
relatively straightforward to accomplish by removing all
infected foreign body and nonvascularized tissue. As the
tissues within the wound become compromised from pre­
vious surgery, smoking, and radiation, the scar and isch­
emic tissue act as ‘‘locus minoris resistentiae’’ and a nidus
where bacteria can reside in low levels for many months
or years. In contradistinction to the requirement of more
than 105 organisms per gram of tissue for most soft tissue
infections to develop, when a foreign body or nonviable
tissue is present, infection can occur with as little as 102
bacteria.49 This may explain the high failure rate of allo­
plastic material used in a previously infected hostile en­
vironment.
It is useful to differentiate these wounds:
1. Acutely infected, characterized by features of cellulitis
or purulent drainage
2. Previously infected or contaminated wounds, charac­
terized by absence of acute features
In the former scenario, we advocate for a radical débride­
ment of infected or nonvitalized tissues, hardware or im­
plant removal, and obtaining bacteriologic balance of the
wound and acute or subacute reconstruction with vascu­
larized tissue only (bone and soft tissue). In large defects,
Fig. 54.17 (a) Computed tomography of a patient who had an infected polyetheretherketone implant removed and immediate reconstruc­
tion with vascularized bone (rib and scapula tip). (b) Evidence of bone-to-bone healing (circles) at the second stage 5 months later. (c) Split
calvarial bone graft (SCBG) filling in the bony deficits during the second stage.
a
b
c

1017
Chapter 54 Reconstruction of the Scalp and Cranium
and muscle atrophies. The atrophy of the muscle reveals
every imperfection of the underlying skeletal construct
(or its secondary changes) it once effectively masked. Be­
yond muscle, we have noted that all soft tissue contracts
and “wraps around” the underlying construct. Sometimes,
this phenomenon is masked by persistent swelling, which
may take up to 2 years or more to resolve. As the contrac­
tion increases and the swelling decreases, the underlying
parts of the reconstruction are vulnerable to show and, in
extreme cases, extrusion. We use the term “shrink-wrap”
to describe this inevitable phenomenon (Fig. 54.19). Rec­
ognizing this effect, particularly the persistence of subclini­
cal swelling for 2 years beyond the last intervention or soft
tissue insult, should temper the desire to debulk soft tissue
flaps too much or too early. In addition, such observations
are useful because they help the surgeon inform the patient
of the long-term outcomes of the reconstruction, the reason
to delay revisions, and the overall limitations of reconstruc­
tive surgery. To restore a satisfactory contour, optimize out­
comes, and minimize unfavorable results, the surgeon must
be prepared to perform minor revisions, such as hardware
removal, soft or hard tissue contouring, or local tissue rear­
rangements.
removal of such exposed implants, drainage, wash out and
débridement of the wound, and reconstruction with vas­
cularized bone. As mentioned previously, if the skeletal re­
quirements of the osseous defect exceed that which can be
safely supplied by vascularized bone and the wound is not
acutely infected, then a “hybrid” cranioplasty of nonvascu­
larized and vascularized bone is used.
Late Effect of Free Tissue Transfer
in Complex Scalp Defects: The “Shrink-
Wrap” Phenomenon
Despite the most elegant, sophisticated, and gratifying
reconstruction of a complex, composite scalp defect, the
surgeon is often humbled and left helpless by the late ef­
fects of the surgery, which may come several years after
the surgery was performed. Even though the wound may
remain closed and the reconstructed parts stable, contour
irregularities may appear with time (Fig. 54.18).
Nonvascularized split calvarial bone grafts have unpre­
dictable resorption rates, vascularized bone remodels ac­
cording to the stress and strains put upon it (Wolff’s law),
Fig. 54.18 The same patient as in Fig. 54.16, 6 months later. (a) Posterior view. (b) Vertex view. Soft tissue contracture occurred over the
skeletal reconstruction, the shrink-wrap phenomenon.
a
b
Fig. 54.19 Examples of the shrink-wrap phenomenon in different patients.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1018
two scalp flaps in terms of tensile strength and vascularity
(Fig. 54.21). For this reason, we are in favor of large flaps
and hardware off incisional lines.
Conclusion
Scalp and cranial defects are some of the most challenging
problems to the reconstructive surgeon and demand a full
array of procedures in the surgical armamentarium. Adher­
ence to guiding principles of wound coverage such as re­
placing like with like will maximize success in the most de­
manding situations. Hostile conditions are best approached
with an autologous and, more specifically, vascularized so­
lution to the reconstructive problem. Vascularized bone is
more tolerant in this environment and, in our experience,
results in enhanced bony union, the highest likelihood of
long-term success, and minimization of unfavorable results.
Avoiding Hardware Directly Under
Incisions
Often, when scalp defects are complex and demand com­
posite reconstruction, internal fixation of bone, whether
vascularized or nonvascularized, is required. In such cases,
it is strongly advisable to place hardware in strategic points
to avoid direct placement underneath incisional closure
lines. It is also important to secure all edges of prosthet­
ics and plates, as it appears that the free edge seems to get
lifted, whether by recall memory of the prosthetic itself or
from the forces of wound contraction (Fig. 54.20). Com­
monplace to patients with a history of cigarette smoking,
irradiated tissue, or repeatedly operated tissue is the ap­
pearance of exposed hardware weeks to months after cra­
nioplasty due to placement of the hardware directly under
the incision, which represents a “watershed” area between
Fig. 54.20 (a) Edges of titanium mesh extruding through the skin, years after insertion. (b) At exploration, the entire edge of titanium
mesh, which had not been secured, lifted up.
a
b
Fig. 54.21 The most likely site for hardware exposure is at incisions,
especially when the hardware is not secured well (notably, there are
no screws in the holes of the extruding plate).
References
1. Gottlieb LJ, Krieger LM. From the reconstructive ladder
to the reconstructive elevator. Plast Reconstr Surg 1994;
93(7):1503–1504
2. O’Brien BM, Drake JE. Congenital defects of the skull and
scalp. Br J Plast Surg 1960;13:102–109
3. Seitz IA, Gottlieb LJ. Reconstruction of scalp and forehead
defects. Clin Plast Surg 2009;36(3):355–377
4. Beasley NJ, Gilbert RW, Gullane PJ, Brown DH, Irish JC,
Neligan PC. Scalp and forehead reconstruction using free
revascularized tissue transfer. Arch Facial Plast Surg 2004;
6(1):16–20
5. Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction
of scalp defects with free flaps in 30 cases. Br J Plast Surg
1998;51(3):186–190
6. Labow BI, Rosen H, Pap SA, Upton J. Microsurgical recon­
struction: a more conservative method of managing large
scalp defects? J Reconstr Microsurg 2009;25(8):465–474
7. Lee JC, Kleiber GM, Pelletier AT, Reid RR, Gottlieb LJ. Au­

1019
Chapter 54 Reconstruction of the Scalp and Cranium
27. Raposio E, Nordström REA, Santi P. Aesthetic reconstruc­
tion of the vertex area of the scalp. Case report. Scand J
Plast Reconstr Surg Hand Surg 1998;32(3):339–341
28. Yap LH, Langstein HN. Reconstruction of the scalp, cal­
varium, and forehead. In: Aston SJ, Beasley RW, Thorne
CHM, et al, eds. Grabb and Smith’s Plastic Surgery. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2007:358–366
29. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trape­
zius musculocutaneous flap revisited: versatile coverage
for complicated wounds to the posterior cervical and oc­
cipital regions based on the deep branch of the transverse
cervical artery. Plast Reconstr Surg 2002;109(2):444–450
30. Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocu­
taneous flap for secondary head and neck reconstruction.
Am J Otolaryngol 1999;20(5):287–293
31. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in
chronic osteomyelitis: experimental and clinical correla­
tion. Plast Reconstr Surg 1982;69(5):815–829
32. Eshima I, Mathes SJ, Paty P. Comparison of the intracel­
lular bacterial killing activity of leukocytes in musculo­
cutaneous and random-pattern flaps. Plast Reconstr Surg
1990;86(3):541–547
33. Schlenker JD, Indresano AT, Raine T, Meredith SC, Rob­
son MC. A new flap in the dog containing a vascularized
rib graft—the latissimus dorsi myoosteocutaneous flap. J
Surg Res 1980;29(2):172–183
34. Schmidt DR, Robson MC. One-stage composite reconstruc­
tion using the latissimus myoosteocutaneous free flap.
Am J Surg 1982;144(4):470–472
35. Robson MC, Zachary LS, Schmidt DR, Faibisoff B, Hek­
matpanah J. Reconstruction of large cranial defects in the
presence of heavy radiation damage and infection uti­
lizing tissue transferred by microvascular anastomoses.
Plast Reconstr Surg 1989;83(3):438–442
36. Seitz IA, Adler N, Odessey E, et al. Latissimus dorsi chi­
meric free flap reconstruction in complicated scalp and
calvarial defects. Plast Reconstr Surg 2008;122(Suppl 4):
116–117
37. Aviv JE, Urken ML, Vickery C, Weinberg H, Buchbinder D,
Biller HF. The combined latissimus dorsi-scapular free
flap in head and neck reconstruction. Arch Otolaryngol
Head Neck Surg 1991;117(11):1242–1250
38. Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg
Oncol 2006;94(6):504–508
39. McLean DH, Buncke HJ Jr. Autotransplant of omentum to
a large scalp defect, with microsurgical revascularization.
Plast Reconstr Surg 1972;49(3):268–274
40. Alday ES, Goldsmith HS. Surgical technique for omental
lengthening based on arterial anatomy. Surg Gynecol Ob­
stet 1972;135(1):103–107
41. Hultman CS, Carlson GW, Losken A, et al. Utility of the
omentum in the reconstruction of complex extraperito­
neal wounds and defects: donor-site complications in 135
patients from 1975 to 2000. Ann Surg 2002;235(6):782–
795
42. Fodstad H, Love JA, Ekstedt J, Fridén H, Liliequist B. Effect
of cranioplasty on cerebrospinal fluid hydrodynamics in
patients with the syndrome of the trephined. Acta Neuro­
chir (Wien) 1984;70(1-2):21–30
43. Suzuki N, Suzuki S, Iwabuchi T. Neurological improve­
ment after cranioplasty. Analysis by dynamic CT scan.
Acta Neurochir (Wien) 1993;122(1-2):49–53
tologous immediate cranioplasty with vascularized bone
in high-risk composite cranial defects. Plast Reconstr Surg
2013;132(4):967–975
8. Hussussian CJ, Reece GP. Microsurgical scalp reconstruc­
tion in the patient with cancer. Plast Reconstr Surg 2002;
109(6):1828–1834
9. Fong AJ, Lemelman BT, Lam S, Kleiber GM, Reid RR, Got­
tlieb LJ. Reconstructive approach to hostile cranioplasty:
a review of the University of Chicago experience. J Plast
Reconstr Aesthet Surg 2015;68(8):1036–1043
10. TerKonda RP, Sykes JM. Concepts in scalp and forehead
reconstruction. Otolaryngol Clin North Am 1997;30(4):
519–539
11. Raposio E, Santi P, Nordström REA. Effects of galeotomies
on scalp flaps. Ann Plast Surg 1998;41(1):17–21
12. Bennett RG. Mohs’ surgery. New concepts and applica­
tions. Dermatol Clin 1987;5(2):409–428
13. Rhee ST, Colville C, Buchman SR, Muraszko K. Complete
osseous regeneration of a large skull defect in a patient
with cutis aplasia: a conservative approach. J Craniofac
Surg 2002;13(4):497–500
14. Becker GD, Adams LA, Levin BC. Secondary intention
healing of exposed scalp and forehead bone after Mohs
surgery. Otolaryngol Head Neck Surg 1999;121(6):751–
754
15. Robinson EF. Total avulsion of the scalp. Surg Gynecol Ob­
stet 1908;7:663
16. Pitkanen JM, Al-Qattan MM, Russel NA. Immediate cov­
erage of exposed, denuded cranial bone with split-thick­
ness skin grafts. Ann Plast Surg 2000;45(2):118–121
17. Komorowska-Timek E, Gabriel A, Bennett DC, et al. Artifi­
cial dermis as an alternative for coverage of complex scalp
defects following excision of malignant tumors. Plast Re­
constr Surg 2005;115(4):1010–1017
18. Koenen W, Goerdt S, Faulhaber J. Removal of the outer
table of the skull for reconstruction of full-thickness scalp
defects with a dermal regeneration template. Dermatol
Surg 2008;34(3):357–363
19. Gottlieb LJ, Parsons RW, Krizek TJ. The use of tissue ex­
pansion techniques in burn reconstruction. J Burn Care
Rehabil 1986;7(3):234–237
20. Iwahira Y, Maruyama Y. Expanded unilateral forehead flap
(sail flap) for coverage of opposite forehead defect. Plast
Reconstr Surg 1993;92(6):1052–1056
21. Gottlieb LJ, Dreyfuss DA. Tissue expander in head and
neck reconstruction. In: Bardach J, ed. Local Flaps and
Free Skin Grafts in Head and Neck Reconstruction.
St ­Louis: Mosby; 1992:132–43
22. Fudem GM, Orgel MG. Full-thickness erosion of the skull
secondary to tissue expansion for scalp reconstruction.
Plast Reconstr Surg 1988;82(2):368–369
23. Iida N, Ohsumi N, Tonegawa M, Tsutsumi Y. Reconstruc­
tion of scalp defects using simple designed bilobed flap.
Aesthetic Plast Surg 2000;24(2):137–140
24. Vecchione TR. Multiple pinwheel scalp flaps. In: Strauch
B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia
of Flaps, Vol. 1. Boston: Little, Brown; 1990:10–12
25. Orticochea M. Four flap scalp reconstruction technique.
Br J Plast Surg 1967;20(2):159–171
26. Lesavoy MA, Dubrow TJ, Schwartz RJ, Wackym PA, Eisen­
hauer DM, McGuire M. Management of large scalp defects
with local pedicle flaps. Plast Reconstr Surg 1993;91(5):
783–790

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1020
48. Heller WA, Gottlieb LJ, Zachary LS, Finn HA. The use of
quantitative bacteriologic assessment of bone. Plast Re­
constr Surg 1997;100(2):397–401
49. Elek SD. Experimental staphylococcal infections in the
skin of man. Ann N Y Acad Sci 1956;65(3):85–90
50. Zins JE, Moreira-Gonzalez A, Papay FA. Use of calcium-
based bone cements in the repair of large, full-thickness
cranial defects: a caution. Plast Reconstr Surg 2007;120(5):
1332–1342
51. Mittermiller P, Hoffman W. Alloplastic cranioplasty out­
comes in previously infected sites. Presented at 2011
AAPS Meeting, Boca Raton, FL
44. Marchac D, Greensmith A. Long-term experience with
methylmethacrylate cranioplasty in craniofacial surgery. J
Plast Reconstr Aesthet Surg 2008;61(7):744–752, discus­
sion 753
45. Manson PN, Crawley WA, Hoopes JE. Frontal cranioplasty:
risk factors and choice of cranial vault reconstructive ma­
terial. Plast Reconstr Surg 1986;77(6):888–904
46. Tessier P, Kawamoto H, Posnick J, Raulo Y, Tulasne JF,
Wolfe SA. Complications of harvesting autogenous bone
grafts: a group experience of 20,000 cases. Plast Reconstr
Surg 2005; 116(5 Suppl)72S–73S, discussion 92S–94S
47. Krizek
TJ,
Robson
MC.
Evolution
of
quantitative
bacteriology in wound management. Am J Surg
1975;130(5):579–584
Discussion by Salvatore C. Lettieri
The anatomy of the cranium makes for a difficult re­
construction because of the terminal blood supply, and
(unlike the foot and ankle area, for example), aesthetics
play a very large part. Outcomes can be optimized by
including several key factors in the reconstructive plan.
These factors are presented here as practical applica­
tions to minimize adverse outcomes.
Simple Closure with an External
Device
A defect of the scalp can occur with the bone remaining
intact. The causes can include cancer resection, trauma,
dog bites, and other incidents. Available options for clo­
sure include immediate scalp flap with grafting of the
donor site, placement of a glycosaminoglycan substrate
with eventual grafting, or a commercially available
external closure device (DermaClose RC, Wound Care
Technologies).1
Defects of the hair-bearing scalp are readily ame­
nable to closure with such a device with undermining
within the subgaleal space. For defects that are on the
periphery, there is risk of a nonfavorable repositioning
of tissue. For example, with a defect in the frontal hair­
line, the forehead skin will be pulled cephalad and pos­
sibly pull up on the eyebrow and result in a unilateral
browlift with unintended consequences. To create a uni­
lateral expansion, screws are placed on one side, then
the scalp is pulled forward without any cephalad pull
of the forehead (Fig. 54D.1).
Patient Positioning for Flaps
Positioning must be addressed with a team approach.
For an extensive resection and reconstruction, the
choice of flap, inflow vessels, and donor closure all
must be considered.2 Often, the neurosurgery team
uses a type of navigation that may fix the head in a cer­
tain position, although some new navigation systems
do not require rigid fixation. The patient is typically po­
sitioned supine, but lateral or even prone positioning
are sometimes used. If a scalp flap is used, the donor
area will need exposure, with the Mayfield pins kept
out of the operative field; with free tissue transfer, the
surgeon will need access to the donor vessels.
The superficial temporal vessels are most readily ac­
cessible in the lateral position, but they can be accessed
in the supine or prone positions with appropriate turn­
ing of the head. If the superficial temporal vessels are not
available, the neck line is attempted next. The common
facial vessels and the external carotid region are best ap­
proached in the supine position. The lateral position is
possible for common facial vessels and external carotid
Table 54D.1 Flap choices
Flap choice
Position
Rectus abdominis/
TRAM/VRAM
S
ALT
S, L
Groin/iliac crest
S
Fibula
S, L, P
Latissimus dorsi
L, P
Scapular/parascapular
L, P
Radial forearm
S, L
Abbreviations: ALT, Anterior lateral thigh; L, lateral decubitus; P,
prone; S, supine; TRAM, transverse rectus abdominis; VRAM, verti­
cal rectus abdominis.

1021
Chapter 54 Reconstruction of the Scalp and Cranium
Fig. 54D.1 (a) A scalp defect at the frontal hairline. All the hair has been clipped
short, but some has been left to reveal the direction of the hair growth. Multiple
screws were placed through the anterior skin edge to act as an anchor, with the clips
secured by staples to the moving edge. (b) The external closure device is placed
after a subgaleal dissection in the apical direction. (c) The wound has been closed
after 10 days. There is no movement of the forehead skin, avoiding any distortion
of the anterior facial landmarks. (d) The skin edges are excised and the defect is
closed. This technique provides a unilateral expansion of the scalp tissue and pre­
vents changes in the appearance of the anterior facial structures.
a
b
c
d
gion, beneath the mandible angle. This puts the mar­
ginal mandibular nerve at risk, but this is an acceptable
chance considering the need to cover the defect (Fig.
54D.2). The external carotid can also be accessed from
posterior to the sternocleidomastoid muscle (Fig.
54D.3). This is especially useful when the flap will cover
the posterior head, such as the occipital region.
The occipital vessels may be usable in the poste­
rior head region, but the vena comitans are quite small
and fragile and not reliable for flaps. The internal jugu­
lar vein and external carotid artery are accessible from
this posterior position, but there are few side branches,
and thus these require end-to-side anastomoses. How­
access, but the shoulder impedes an easy dissection. The
prone position has limited recipient vessel access, with
the external carotid (posterior to the sternocleidomas­
toid) and the superficial temporal vessels providing the
best choices. The flap choice and location should also
minimize the need to move the patient. The optimal
scenario would be a single prep and drape to include
the donor area, recipient area, and the vessels, both for
pedicled and free tissue transfers. The lateral and supine
positions allow several flap choices (Table 54D.1).
Donor Vessel
There are a limited number of vessels available for free
tissue transfer. The size and location of the vessels will
dictate the flap inset and the possible need for vein
grafting. The superficial temporal vessels are in the
vicinity of the scalp and allow an easier inset but are
limited in size.
The primary issue is with chronic inflammation in
the region. There is a tendency for the superficial tem­
poral vessels to be subject to low-grade inflammation,
and the vessels may not dissect as readily as when there
is no inflammation. Chronic open wounds from infec­
tion or regional effects of advanced malignancies are
also concerns. These vessels are limited in the dissec­
tion toward the external carotid system, because the fa­
cial nerve passes over the artery and vein just below the
zygomatic process of the temporal bone.
The next choices are the facial vessels or the exter­
nal carotid. The common facial vein is in the same re­
Fig. 54D.2 The external carotid artery and the most proximal
branches are available for inflow. The common facial vein and
the internal jugular vein provide good outflow. The external jug­
ular vein is prone to external compression postoperatively and
should be used when other sites are not practical or available.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1022
ever, with anterior access, external carotid and venous
systems typically have sufficient branches amenable to
end-to-end anastomoses.
With regional flaps, there is less concern over the
pedicle because the flap itself will act as a protective
cover. The regional flaps are rotated into position with
either tunneling or splitting of the skin bridge and pres­
sure relief.
The free tissue transfers have more potential prob­
lems with compression. The bridge of tissue will need
to have enough laxity to prevent compression. The op­
tions include laying the tissue just beneath the skin,
cutting a trough in the deep tissue layer, or splitting
the skin bridge and laying a portion of the flap over the
area. The angle of the mandible must also be consid­
ered if the vessels below the mandible are used, which
also creates a risk for compression from movement of
the mandible or from external compression (such as
an oxygen mask). The pedicle can be passed deep to
the mandible in the position of the medial pterygoid
muscle. With defects in the lateral head, the deep ac­
cess is readily available. For coverage in areas further
toward the vertex, this approach is not practical, and
the pedicle can be passed posterior to the angle, but
care should be taken to avoid compression over the
firm underlying mandible.
Vein grafts that lie along the skull present a risk for
compression. The flap or the scalp will press against the
pedicle and present a mass effect that can, in turn, com­
press the pedicle or vein grafts. A burr can be used to
carve a trough in the outer table of the skull. The ped­
icle can lay within the trough and be protected from
external pressure by the surrounding bone. This is an
especially important maneuver to alleviate one of the
­potential causes of flap compromise with long vein
grafts3 (Fig. 54D.4). The outer cortex can be removed
with a round cutting burr down to the inner table. The
diploe layer will bleed and should be removed also. Once
the inner table is uncovered, the bleeding will subside.
In the region of the skull sutures, there is no diploe layer,
but the depth is created to match the outer layer and
diploe layer removal on either side.
Fig. 54D.3 (a) Posterior scalp coverage is difficult for vascular inflow and outflow. The external carotid artery and internal jugular
vein can be accessed posterior to the sternocleidomastoid muscle. (b) There are no major branches that are readily apparent or
reliably available that would require end-to-side anastomoses.
a
b
a
b
c
Fig. 54D.4 (a) The hard surface of the skull creates a risk of compression of the pedicle. With this long vein graft, the flap lies over
the pedicle. A trough was created with a round cutting burr through the outer cortex, removing the diploe layer and leaving the
inner cortex. (b) The vein graft is protected by the walls of the trough. (c) The vessels remain protected when they dilate.

1023
Chapter 54 Reconstruction of the Scalp and Cranium
Table 54D.2 Cranioplast materials
Material
••••••••
Methylmethacrylate
I
Titanium mesh
I
Titanium block
CI
Sodium
monophosphate
I
Porous polyethylene
I, CI
Polyetheretherketone
CI
Hydroxyapatite
I, CI
Abbreviations: I, Immediate; CI, custom implant.
Flap Protection
Flaps in the head region have specific postoperative
protective care issues. An external fixation device is an
effective method of protecting head flaps. A Mayfield
device with pins can be left attached to the bone and
the U-bar placed posterior and rested on a firm surface.
Pillows are not allowed, because they are counterpro­
ductive to the intent of pressure relief, possibly pushing
around the frame and against the flap.
The use of the Mayfield should be considered tem­
porary and only if an immediate solution is required.
The best option is a halo ring. The halo ring comes in
different sizes, but the largest ring should be used to
allow for expansion of the flap. It can also be used for
total skull skin graft placements, such as in burn care
or extensive scalp resection treated with graft rather
than flap. The pins for the halo are placed in the fron­
tal and posterior parietal or occipital areas. The cri­
teria used for placement with a halo vest jacket need
not be followed. The full halo vest jacket is intended
to keep the cervical spine in fixed position for several
weeks. The intent in this case is simply for flap protec­
tion (Fig. 54D.5).
Secondary Cranioplasty
The type of flap performed for a secondary cranioplasty
largely depends on the comfort level of the surgeon and
the positioning of the patient. The options are a muscle
flap with skin graft, myocutaneous flap, omentum with
skin graft, fasciocutaneous flap, and various vascular­
ized bone and soft tissue flaps.
The muscle flaps will generally heal well and pro­
vide well-vascularized coverage of the bone or dura de­
pending on the defect. For muscle flaps, the interface
between the dura and dura replacement is scar tissue,
and the muscle itself will atrophy and become thinner
and has a secondary effect similar to denervated mus­
cle. With a fasciocutaneous flap or omentum, the tis­
sue retains its normal state. Once the flap has healed
and the edema subsided, it will have the same consti­
tution as the donor site and be more predictable for el­
evation. The Millard crane principle can be beneficial
when elevating the flap. A small layer of fat can be left
if needed. This provides a safer elevation for second­
ary procedures. There are several materials that can be
used (Table 54D.2), but recent experience with a poly­
etheretherketone, custom-made implant has been en­
Fig. 54D.5 (a) When flaps are placed in the posterior scalp, protection is vital. The intraoperative Mayfield with pins is a fast and
readily available device to keep pressure off the flap. It is heavy and not practical for long-term use but can be used as a bridge to
a halo. (b) If available, a halo ring is the best option. The pins provide support. Because a vest jacket is not used, the surgeon has
more liberty with the location of the pins. It is used solely for pressure relief and flap protection. A pillow should not be placed
beneath the halo, because it will can push up around the halo and compress portions of the flap.
a
b

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1024
couraging.4 The keys to a successful outcome are a stable
and well-healed wound bed and avoiding placement of
the incision over the implant. The cranioplasty can be
staged by moving the incision away from the edge of
the bone. This is easiest to accomplish with tissue ex­
pansion. The process is longer and takes several weeks,
but the outcome is more predictable and may be worth­
while (Fig. 54D.6).
Fig. 54D.6 (a,b) After removal of an implant, this patient had a chronically infected and radiated dura/dural replacement. (c) Pu­
rulence was evident beneath the implant. (d) Free tissue transfer was determined the best option with an expanded parascapular
flap. (e) After 4 months, the flap is well healed without infection and then lifted off the previously infected and scarred dura. The
wound bed has a little fat left on it during the dissection. (f) A custom-made implant was placed (polyetheretherketone). (g) The
patient has no contour irregularity, the hostile wound bed has cleared, and there is stable soft tissue coverage.
a
b
c
d
e
f
g
References
1. Reinard KA, Zakaria HM, Qatanani A, Lee IY, Rock JP,
Houin HP. Preoperative external tissue expansion for
complex cranial reconstructions. J Neurosurg 2016;
125(4):861–868
2. Lettieri SC. Flap choices and patient positioning in
advanced skull base extirpative procedures. Barrow
Quarterly 2013;25(1):17–23
3. Deshmukh VR, Porter RW, Spetzler RF. Use of “bonnet”
bypass with radial artery interposition graft in a pa­
tient with recurrent cranial base carcinoma: technical
report of two cases and review of the literature. Neu­
rosurgery 2005; 56(1 Suppl)E202, discussion E202
4. Rammos CK, Cayci C, Castro-Garcia JA, Feiz-Erfan I,
Lettieri SC. Patient-specific polyetheretherketone im­
plants for repair of craniofacial defects. J Craniofac
Surg 2015;26(3):631–633

1025

Eyelid Reconstruction
Chris Alabiad and Bradford W. Lee
The eyelids are challenging structures to reconstruct be­
cause of their unique anatomy, their juxtaposition to a sen­
sitive and vital organ, and their location as the aesthetic
focal point of the face. The stakes are high, and patient ex­
pectations are even higher. An asymmetry as small as 1 to
2 mm is often perceived as an unacceptable complication
by the patient.
It is imperative to remember that the most important
goal of eyelid reconstruction is to protect the globe. Poorly
repaired eyelids leave the globe susceptible to corneal ex­
posure, corneal abrasions and scarring, or even a ruptured
globe.
Postoperative complications in eyelid reconstruction can
be avoided through proper surgical decision-making and
reconstructive techniques. This chapter reviews key eyelid
anatomy, identifies surgical strategies to reconstruct specific
components of the eyelids, and offers surgical pearls to pre­
vent and correct common complications.
Anatomy
The eyelids play a critical role in maintaining ocular health
by serving as a barrier between the globe and the outside
world. They also sustain tear homeostasis by distributing
tears evenly across the ocular surface and draining tears
through the puncta and nasolacrimal system. This is ac­
complished when the eyelids are oriented and functioning
properly.
Key Components of Orientation
Apposition of the Eyelids to the Globe
Proper apposition of the eyelids to the globe prevents des­
iccation of the ocular surface and keeps the puncta in con­
tact with the upper and lower lid tear meniscus. Disruption
of this anatomic relationship causes significant ocular sur­
face irritation and ineffective tear drainage. Entropion (in-
turned eyelid) irritates the ocular surface by chafing with
the eyelashes and keratinized skin. Ectropion (out-turned
eyelid) distracts the lid from the globe and leaves the ocular
surface exposed without proper lubrication (Fig. 55.1).
Horizontal Stabilization
Horizontal stabilization or tension, through firmly an­
chored medial and lateral canthal tendons to the orbital
rim, gives the characteristic V appearance to the medial
and lateral canthi. The tendons stabilize the eyelids dur­
ing contraction of the orbicularis oculi muscle during the
blink. Without sufficient horizontal tension on the eyelid,
the horizontal palpebral fissure (the distance between the
medial and lateral canthus) narrows and pseudo–eyelid re­
traction develops. This can affect blink dynamics and cause
incomplete closure of the lids.
Proper Vertical Positioning of the Upper
and Lower Lids
The lower eyelid should rest at the inferior limbus, the infe­
rior border of the cornea, whereas the upper eyelid should
rest 1 to 2 mm below the superior limbus.
Key Components of Function
Adequate Innervation of the Orbicularis Oculi
Muscle without Mechanical Obstruction
The temporal and zygomatic branches of the facial nerve
maintain orbicularis oculi tone and facilitate a complete
blink. The blink not only distributes tears along the ocu­
lar surface but also contracts the lacrimal sac. This latter
CHAPTER
55

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1026
a
b
c
Fig. 55.1 (a) Proper lid position. (b) Entropion. (c) Ectropion.
Fig. 55.2 Eyelid anatomy. (a) Sagittal view (including the layers of the upper and lower eyelids). (b) Tendinous attachments. (Reproduced
from Codner MA, McCord CD. Eyelid and Periorbital Surgery. 2nd ed. New York: Thieme Medical; 2016.)
Orbital septum
Whitnall’s ligament
Levator aponeurosis
Müller’s muscle
Tarsus
Orbicularis oculi muscle
Inferior tarsal muscle
Inferior oblique muscle
Inferior rectus muscle
Superior rectus muscle
Levator palpebrae
superioris muscle
Capsulopalpebral fascia
Orbital septum
Lockwood’s ligament
a
Whitnall’s ligament
Musculoaponeurotic
junction
Lateral horn
of levator
Levator muscle
Levator aponeurosis
Medial horn of levator
Tarsus
Inferior retractors
(capsulopalpebral fascia)
b
Continued

1027
Chapter 55 Eyelid Reconstruction
Above the superior tarsal border of the upper eyelid, the
anterior lamella remains the same, but additional structures
come into play. The orbital septum, also known as the mid­
dle lamella, is a dense layer of connective tissue that sepa­
rates the eyelid from the vital orbital structures posteriorly.
This includes preaponeurotic fat, the levator aponeurosis,
Müller’s muscle, and the conjunctiva. The same arrangement
is seen in the lower lid, except the lower eyelid retractors
are referred to as the capsulopalpebral fascia (see Fig. 55.2).
Avoiding Unfavorable Results
and Complications in Eyelid
Reconstruction
Surgical Planning
Before beginning to reconstruct the eyelids, it is critical to
ensure that any eyelid neoplasm has been adequately re­
sected and that biopsied tissues have been reviewed by
a trusted pathologist. If a patient is referred from an out­
side facility, the pathology slides should be obtained and
reviewed to confirm the diagnosis. In cases where this is
not possible, repeat biopsy may be indicated. A metastatic
workup should be performed when indicated (e.g., mela­
noma, large sebaceous carcinoma) before planning total
tumor resection.
Adequate surgical planning prevents most complica­
tions. A thorough review of the patient’s past history is
undertaken to identify risk factors for complications. Mi­
crovascular disease resulting from hypertension, hyperlip­
idemia, diabetes mellitus, radiation exposure, or tobacco use
can affect postoperative tissue perfusion, although the inci­
dence of postoperative vascular complications is low in the
function is a vital component in the physiology of tear
drainage. Weakened or absent orbicularis tone can lead to
lagophthalmos, brow ptosis, and neurogenic lower lid ec­
tropion.
Adequate Positioning and Function of
the Levator Palpebrae Superioris without
Mechanical Obstruction
The levator is the main elevator of the eyelid and inserts on
the anterior face of the tarsal plate. The levator also sends
anterior projections to the skin and orbicularis muscle that
create the eyelid crease. The upper lid crease varies in its
presence and position according to ethnicity. Disinsertion
or weakening of the levator causes varying degrees of pto­
sis that can obstruct part or all of the visual field, whereas
fibrosis or scarring of the levator can result in upper eyelid
retraction.
Understanding several key aspects of eyelid anatomy
is critical for a successful reconstruction. Starting from the
eyelid margin, the first 10 to 12 mm of the upper lid and the
first 4 mm of the lower lid have similar anatomic layers: the
skin, orbicularis oculi muscle, tarsal plate, and conjunctiva1
(Fig. 55.2). Oculoplastic surgeons group these layers into
reconstructive units, the anterior lamella (skin and orbicu­
laris oculi muscle) and the posterior lamella (tarsal plate and
conjunctiva). Conjunctiva lines the posterior aspect of the
eyelids and extends into the upper and lower lid fornices,
invaginations where the eyelids fuse with the ocular surface.
The conjunctiva is a nonkeratinized mucus membrane that
secretes mucus into the overlying tear film. This allows for
a smooth glide across the sensitive ocular surface with each
blink. The puncta are located at the medial aspect of the up­
per and lower lid margin and are responsible for draining the
tears through the nasolacrimal system.
Nasal fat pad
Interpad septum
Central fat pad
Path of inferior
oblique muscle
Interpad septum
(arcuate expansion of
Lockwood’s ligament)
Temporal fat pad
Lacrimal gland
Preaponeurotic fat pad
c
Fig. 55.2, cont’d Eyelid anatomy. (c) Fat pads. (Reproduced from Codner MA, McCord CD. Eyelid and Periorbital Surgery. 2nd ed. New York:
Thieme Medical; 2016.)

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1028
clean margins should be viewed warily, because orbital fat
involvement is often associated with residual microscopic
disease (Fig. 55.3). Definitive reconstruction in this setting
or any setting where tumor cannot be cleared should be de­
ferred. Temporizing measures are taken to protect the globe
and maintain patient comfort as further treatment plans are
considered. These patients require close follow-up, because
more extensive treatment such as radiation or exenteration
of the total orbital contents is often indicated. Valuable re­
constructive options are thus preserved for future use.
In creating a reconstructive plan, the surgeon must take
a systematic approach toward assessing areas of tissue loss,
including the anterior lamella, posterior lamella, medial can­
thus, lateral canthus, and nasolacrimal drainage apparatus.
In addition, if the entire upper or lower lid tarsal plate is ab­
sent, the upper eyelid retractors (particularly the levator pal­
pebrae superioris) and lower eyelid retractors will need to
be reattached to the newly reconstructed posterior lamella.
Repairing the Anterior Lamella
Many options exist for repair of anterior lamellar defects.
Preoperative considerations in anterior lamellar recon­
struction include color and texture match, graft and flap
thickness, and vertical lamellar support.
Color and Texture Match
The eyelid skin is the thinnest and arguably the most vis­
ible skin of the entire body, so the ideal donor site should
optimize color and texture match and be non–hair-bearing
when possible. Skin grafts from the eyelids are the ideal
option for eyelid reconstruction, and excess upper eyelid
skin can often be harvested via a blepharoplasty incision.
In cases where there is insufficient upper lid dermatocha­
lasis, extensive photodamage, history of eyelid cancers, or
scarring that makes eyelid skin grafts otherwise unsuitable,
retroauricular, supraclavicular, pretragal, or medial upper
arm skin can serve as alternative options. Hair-bearing skin
and thicker skin from other parts of the body are cosmeti­
cally inferior (Fig. 55.4).
periocular region.2–4 A careful review of previous periocular
reconstructive surgeries helps identify available tissues for
further reconstruction. For example, if a patient has previ­
ously undergone a Hughes tarsoconjunctival flap, which uses
the posterior lamella of the upper lid to reconstruct the pos­
terior lamella of the lower lid, a second Hughes flap cannot
be performed for a new or recurrent lower eyelid neoplasm.
Many patients may not fully understand their previous re­
constructive procedures, but a review of prior operative re­
ports and careful examination of the eyelids and potential
donor sites will yield evidence of prior tissue manipulation.
In addition, the surgeon can anticipate potential complica­
tions or successes by taking note of previous graft contrac­
ture, scar formation, and flap viability.
Postoperative bleeding complications can cause dev­
astating outcomes, such as skin graft necrosis or a retro­
bulbar hemorrhage causing compressive optic neuropathy.
Appropriate suspension of antiplatelet agents and antico­
agulants is advisable, particularly if there are no grave sys­
temic contraindications. This, in combination with using
local anesthetic mixed with epinephrine and meticulous
intraoperative ­hemostasis, will aid tremendously in reduc­
ing bleeding complications.
Reconstructive planning commences once the eyelid tu­
mor has been excised with clear margins. Most eyelid neo­
plasms are fairly superficial and straightforward to remove,
but aggressive lesions can extend posterior to the orbital
septum and involve the orbital fat. In such cases, a report of
Summary Box
Complications in Eyelid Reconstruction
Anterior lamella
•• Scar formation
•• Cicatricial ectropion
•• Graft/flap necrosis
•• Facial nerve paralysis
•• Medial canthal webbing
Posterior lamella
•• Lid margin notch
•• Eyelid retraction
•• Cicatricial entropion
•• Lateral canthal dystopia
Tear drainage system
•• Canalicular stenosis
Other
•• Retrobulbar hemorrhage
Fig. 55.3 Eyelid defects. (a) Superficial wound. (b) Deep wound with
orbital involvement.
a
b

1029
Chapter 55 Eyelid Reconstruction
also be considered, but it can be temporarily disfiguring and
requires staged surgery over weeks to months to allow for
adequate expansion. Skin grafting should be reserved for
reconstruction that is temporizing or when a more exten­
sive adjacent tissue transfer reconstruction is not possible
or is undesirable based on comorbidities or patient prefer­
ences. Full-thickness grafts are preferred over split-thickness
grafts, because they are less prone to contraction and tex­
tural abnormalities, are more durable, and do not result in
as significant a volume deficit.
Complications in Anterior Lamella Repair
Superficial Scar Formation
Scars in the periocular region can affect dynamic function
of the eyelids by causing cicatricial ectropion, retraction,
or lagophthalmos. However, even when not causing func­
tional lid abnormalities, scars in the periocular region can
be disfiguring if they are hypertrophic or if they have a pig­
mentary or textural mismatch with the surrounding tissue.
Although surgical scar revision always remains an op­
tion, many nonsurgical options exist for scar rehabilitation.
Conservative options that can mildly improve or help pre­
vent undesirable cicatrization include eyelid massage and
silicone strips or gel. Intralesional injections with an an­
tifibrotic agent (e.g., 5-fluorouracil) and/or a steroid (e.g.,
triamcinolone) are useful adjuvants that modulate the
wound-healing process and flatten scars while improving
their pliability5,6 (Fig. 55.6). These injections can be per­
formed as early as 2 to 4 weeks after surgery on a monthly
basis. Injections should be performed slowly and in a retro­
grade fashion to prevent intravascular complications such
as blindness from retrograde flow of medication into the
ophthalmic artery with subsequent retinal artery occlusion
Graft and Flap Thickness
Anterior lamellar skin defects may or may not involve the
underlying orbicularis muscle, and reconstruction should
ideally account for all missing layers to maintain appropri­
ate eyelid volume. If orbicularis is missing, a skin–muscle
flap can be used in reconstruction to account for the vol­
ume deficit. Small defects should be closed primarily when
possible, after undermining adjacent tissue (Fig. 55.5).
Larger defects that can be closed primarily may require de­
bulking of the orbicularis to prevent tissue bunching or to
allow for closure using a skin–muscle flap.
Vertical Lamellar Support
The eyelids are particularly sensitive to vertical vector
forces. These changes lead to eyelid retraction or cicatricial
ectropion and symptoms of ocular irritation. These vertical
vectors are particularly relevant in situations such as with
skin graft contraction, primary closures that recruit tissue
in a vertical fashion, and bulky myocutaneous flaps involv­
ing the midface that are not adequately suspended to the
periosteum. Horizontal laxity of the eyelid adds an addi­
tional layer of complexity, because lax lids are even more
sensitive to the effects of vertical vector forces. Tightening
the lower eyelid with a slight supraplacement at the level
of the lateral canthus will provide additional support. This
can be achieved through a lateral canthopexy or lateral tar­
sal strip procedure.
When choosing an approach to reconstruct anterior la­
mella, adjacent tissue transfers using local flaps should be
favored over full-thickness skin grafts, because the former
best address the concerns mentioned previously. In addi­
tion, the robust blood supply in the periocular region facili­
tates a higher success rate. The use of a tissue expander can
Fig. 55.4 Bilateral lower lid skin grafts. (a) Graft using split-thickness skin from the thigh. (b) Graft using retroauricular skin (arrows). The
superior color and texture match of retroauricular skin is quite evident.
a
b
Fig. 55.5 A cutaneous defect (a) closed with primary
closure (b).
a
b

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1030
after ablative laser procedures should be used, including
antiviral prophylaxis to prevent herpes simplex virus re­
activation.
Finally, if surgical revision is required, use of nonabsorb­
able sutures that induce minimal inflammation (e.g., poly­
propylene or nylon) and gentle eversion of the wound edges
will help minimize recicatrization. Postoperatively, patients
should be counseled to avoid sun exposure, wear ultraviolet-
filtering sunglasses, and apply sunscreen.
Cicatricial Ectropion
Identification of ectropion is fairly straightforward. How­
ever, delineating the cause of ectropion poses a bigger
and blindness.7 Care should also be taken when injecting
high-dose steroids in darkly pigmented individuals, because
this can cause hypopigmentation.
Laser scar rejuvenation can be performed using a frac­
tional ablative laser (e.g. CO2)8; erbium-doped: yttrium alu­
minum garnet (Er:YAG); or yttrium, scandium, gallium, and
garnet (YSGG) lasers to improve scar thickness, pliability,
dyschromia, or textural abnormalities. Pulsed-dye lasers
can also be used simultaneously to help eliminate scar red­
ness and telangiectasias. Multiple sessions spaced approxi­
mately 1 to 3 months apart yield the best results. Fractional
ablative lasers can be immediately followed with topical
laser-assisted delivery of steroids or 5-fluorouracil to the
dermis9 (Fig. 55.7). Standard postprocedural precautions
Fig. 55.6 (a) Eyelid cicatrix that formed after periocular trauma. (b) Intralesional injection of triamcinolone and 5-fluorouracil is performed
in a subcutaneous plane with a 27-gauge needle. (c) Marked improvement after full-thickness retroauricular skin graft and three cycles of
intralesional injection.
a
b
c
Fig. 55.7 Cicatricial ectropion managed medically. (a,b) Before treatment. (c,d) After one round of ablative fractional laser resurfacing with
laser-assisted delivery of 5-fluorouracil. (e,f) After a second round of treatment.
a
b
c
d
e
f

1031
Chapter 55 Eyelid Reconstruction
tarsal strip and suborbicularis oculi fat (SOOF) lift may be
adequate to reposition the lid margin and recruit anterior
lamella from the midface. More severe cases require a full-
thickness skin graft to restore anterior lamella to the lower
lid, and this can also be performed in combination with
other techniques.
The best incision to release an eyelid cicatrix is through
a subciliary (lower lid) or supraciliary (upper lid) approach,
because the adjacent eyelashes help to hide the resulting
scars. After marking the incision, a 4–0 silk traction suture
is placed through the Meibomian gland orifices of the lid.
The incision is made, and dissection is directed in the sub­
orbicularis oculi fascial plane. Once the entirety of the ci­
catrix has been released, the eyelid will be well apposed to
the globe. The surgeon assesses this intraoperatively by re­
leasing tension on the traction suture. The defect can then
be closed with a myocutaneous flap or with a full-thickness
skin graft.
When sizing the skin graft, oversizing by approximately
25% larger than the anterior lamellar defect (with the eyelid
on gentle stretch) helps anticipates future graft contracture.
A Frost suture or a tarsorrhaphy can further keep the eye­
lid on stretch for the first few weeks after reconstruction
to counter the vertical contractile forces from the healing
skin graft (Fig. 55.9). Similarly, when creating myocutane­
ous flaps, the flap can be sized to slightly overcorrect the
vertical tissue deficiency, particularly for horizontally ori­
ented flaps. Bulky midface flaps, such as Mustardé flaps, are
subject to gravitational forces and benefit from robust sus­
pension. This can be achieved by slightly supraplacing and
anchoring the flap to the periosteum of the orbital rim (Fig.
55.10) or by securing the flap to the orbital rim through
drill holes.
If the ectropion is still manifest after scar release, the
surgeon will need to reassess and address other causes of
ectropion that could be playing a more significant role than
previously realized.
challenge, particularly in situations that are multifactorial.
A thorough examination of the ocular adnexa will help re­
veal the cause or causes. One helpful diagnostic technique
involves placing the lower lid on superior traction. Suffi­
ciently scarred tissue and tissue tethered to the orbital rim
will be resistant to gentle manual elevation of the lower
eyelid (Fig. 55.8). A patient with cicatricial changes of the
anterior lamella of the lower lid will also have worsening
of ectropion on upgaze or with mouth opening. The eyelid
should also be evaluated for concomitant horizontal laxity
using the lid distraction and “snap-back” tests, and hori­
zontal tightening should be performed when indicated.
Finally, the surgeon should examine the midface to de­
termine to what degree the midface can be lifted superi­
orly to restore support and recruit anterior lamella for the
lower lid.
Mild cases of retraction and ectropion that occur in the
early postoperative period can be managed as described pre­
viously in the management of superficial scars. In cases of
cicatricial ectropion that are of moderate severity, a lateral
Fig. 55.8 Assessing the adequacy of the vertical lamella. (a) A pa­
tient with lower lid retraction. (b) Gentle pressure on the orbital rim
alleviates the retraction and suggests there is adequate anterior la­
mella. Addressing the posterior lamella will resolve the retraction.
a
b
Fig. 55.9 (a) Cicatricial ectropion after right cheek reconstruction (arrows). The patient has retraction and ectropion from vertical lamellar
deficiency. (b) The ectropion became more manifest in upgaze. (c) The scar was released through a subciliary approach and an oversized
full-thickness supraclavicular skin graft. The eyelid is shown on stretch with a Frost suture. (d) The patient has significantly improved posi­
tion of the lower lid.
a
b
c
d

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1032
the point that dermal appendages are identified. Fenestrat­
ing the skin graft, placing bolster sutures, and applying a
pressure dressing all serve to minimize the accumulation of
serosanguinous fluid that can accumulate at the graft–host
interface (Fig. 55.12). Application of the pressure dress­
ing requires special care to ensure that the eye is closed
while it is applied. A dressing placed over an open eye can
cause corneal abrasions and will desiccate the ocular sur­
face. The role for postoperative systemic antibiotics has yet
to be fully examined.
In contrast, local flaps and tissue advancements are
perfused by a robust network of subcutaneous vessels. In
addition to optimizing systemic medical conditions, ensur­
ing that local flaps do not exceed a length-to-width ratio of
2:1 will reduce the risk of flap necrosis. Minimizing tension
on the wound and avoiding excessive cautery will also help
maintain peripheral perfusion.
Axial flaps such as the median, paramedian, and midline
forehead flaps are used with much less regularity for eye­
lid reconstruction. Maintaining the integrity of any source
vessel and avoiding excessive flap rotation around the ped­
icle (usually under 90 degrees) will preserve vessel patency
and prevent kinking. Preoperative Doppler ultrasonogra­
phy can be useful to delineate the course of the supraorbital
Local Flap and Skin Graft Necrosis
Flap and graft failures are frustrating complications but for­
tunately are uncommon in the periocular region because
of the robust and redundant blood supply. Any concern for
graft failure should be followed closely. Prophylactic oral
antibiotics and topical ophthalmic antibiotic ointment help
prevent bacterial superinfection. The role of hyperbaric
oxygen has not been clearly established; however, given
its low risk profile, a referral for treatment can be consid­
ered. Necrotic grafts are débrided and allowed to granulate.
These wounds tend to cicatrize and may require staged sur­
gery, revision surgery, or other interventions for scar reha­
bilitation (Fig. 55.11).
As in other parts of the body, skin grafts are more likely
to fail than local flaps given their dependence on the un­
derlying vascular bed. Skin grafts can be risky in the setting
of concomitant posterior lamellar reconstruction, because
most options for posterior lamellar reconstruction are
avascular tissues (e.g., hard palate grafts, free tarsal plate
grafts, cartilage grafts, donor sclera, or acellular collagen
matrices). The key to a successful skin graft lies in maxi­
mizing blood supply to the avascular graft. After ensuring
a healthy vascular bed, the skin graft should be thinned to
Fig. 55.10 Mustardé flap. (a) The flap has been created. (b) Periosteal bites are taken (arrows) of at least 2 or 3 points along the orbital rim
using 3–0 or 4–0 polypropylene suture. (c) The flap is better supported against the gravitational pull on the lower lid.
a
b
c
Fig. 55.11 A large defect (a) repaired with myocutaneous advancement of the upper eyelid and a midline forehead flap (b). (c) Necrosis of
the distal midline forehead flap several weeks postoperatively. (d) After 3 months of observation, the cosmetic and functional outcomes
are acceptable.
a
b
c
d

1033
Chapter 55 Eyelid Reconstruction
epithelium can be seen to varying degrees depending on the
severity of the paralysis.
Mild facial paralysis may only require aggressive lubri­
cation with artificial tears during the day and ophthalmic
ointment before bed. Moderate and severe facial paralysis
call for surgical intervention. Lower lid tightening through
a lateral tarsal strip procedure is often adequate to correct
a neurogenic ectropion. Placement of a low-profile upper
lid weight made of gold or platinum addresses the lag­
ophthalmos. Using a sizer preoperatively allows the sur­
geon to decide the ideal weight that achieves improved
closure without causing a debilitating mechanical ptosis
(Fig. 55.13).
Medial Canthal Webbing
A common cause of medial canthal webbing is shortage of
anterior lamella. This pitfall often occurs when a flap is be­
ing stretched laterally to medially to cover a defect of the
superior and inferior canthus. It is important to undermine
the surrounding tissue to allow closure of the defect without
tension on the skin, while also ensuring that the V shape of
the canthus is preserved. The flap must also be secured well
to the underlying tissues, because graft dehiscence and scar
formation also contribute to webbing. Repair of a web can
be challenging but can be improved by scar release with a
z-plasty or Y-V plasty (Fig. 55.14).
and supratrochlear arteries. Identification of large bleeders
should be addressed before securing the flap into the de­
fect, because pressure from a postoperative hematoma may
compromise blood flow. Flap division and thinning should
be delayed by at least 3 weeks.
Facial Nerve Paralysis
Temporal and zygomatic branches of the facial nerves sup­
ply the frontalis, corrugator supercilii, and orbicularis oculi
muscles. These branches can be encountered beneath the
superficial temporalis fascia. Branches are also seen overly­
ing the periosteum at the junction of the zygomatic arch
and the lateral orbital rim. The typical dissection plane
around the eyelids is in the postorbicularis fascial plane. At
the level of the lateral orbital rim, dissection in the sub­
cutaneous plane minimizes the possibility of facial nerve
injury. At other times, large parotid lesions or large facial
cutaneous malignancies with perineural spread may di­
rectly involve the facial nerve, requiring sacrifice of some
or all of its branches.
Postoperative facial paralysis warrants prompt recogni­
tion and management because of potential long-term dam­
age to the cornea. Lagophthalmos and lower lid ectropion
are readily detected on external exam. These patients typi­
cally note excessive tearing, foreign body sensation, and
conjunctival injection. Fluorescein staining of the corneal
Fig. 55.12 The use of bolsters (a) and a pressure dressing (b) helps
keep the graft firmly attached to the vascular bed.
a
b
Fig. 55.13 (a) Facial nerve palsy with lower lid ectropion, lagophthalmos, and exposure keratopathy. (b) Improved closure using a gold
weight sized before implantation.
a
b

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1034
Posterior Lamellar Reconstruction
Lid Margin Notching
Even mild notching or misalignment of the eyelid margin
can be very noticeable because of vernier acuity, the abil­
ity of the brain to detect subtle misalignment between two
linear segments. Addressing lid margin notching requires
excising the notched tissue and then reconstructing the lid
margin with proper alignment. In most cases, the notch or
misalignment will be very focal, and the region of interest
can even be merely incised with minimal tissue excised. In
this situation, there will be no appreciable change in the
horizontal tension on the eyelid when closed primarily
(Fig. 55.17). If there is more extensive notching because of
improper reconstruction or wound dehiscence with healing
by secondary intention, excising the notch in a pentagonal
wedge fashion can significantly affect the horizontal ten­
sion on the eyelid. In these cases, the degree of horizontal
laxity of the eyelid should be evaluated preoperatively to
counsel patients on the potential need for a more extensive
eyelid reconstruction.
If the lid margin misalignment is very focal without a
true V-shaped notch, the lid margin can be incised with a
full-thickness vertical incision in the region of the notch. The
incision should extend the full vertical length of the tarsus,
which is approximately 10 mm and 4 mm in length for the
upper and lower lids, respectively. If there is a true V-shaped
notch, the notched region is excised in a pentagonal wedge
Avoiding Complications in Posterior
Lamellar Reconstruction
Repairing Posterior Lamellar Defects
As the structural support of the eyelid, the posterior lamella
plays a critical role in modulating the vertical position of
the upper and lower lids. Reconstruction thus requires the
posterior lamella to be of appropriate height and width, se­
cured to its appropriate eyelid retractors, positioned flush
with the globe, and anchored to its medial and lateral peri­
osteal attachments.
Posterior lamellar defects typically occur when full-
thickness eyelid excisions are performed. Careful posterior
lamellar reconstruction will yield superior functional and
aesthetic outcomes. Considerations include the size of the
defect and the laxity of the residual tissues. Small defects,
up to 33% of the eyelid, can usually be closed in a layered
primary fashion depending on the degree of lid laxity. Ex­
cessive horizontal tension can be alleviated with primary
closure by performing a lateral canthotomy with inferior
cantholysis, because excessive horizontal tension can cause
eyelid retraction. Larger defects of the upper and lower lids
can be repaired by the creation of a semicircular rotational
(Tenzel) flap10 (Fig. 55.15).
When a layered primary closure is not feasible to close a
full-thickness eyelid defect, the posterior lamella must be re­
constructed independently of the anterior lamella. The tarsal
plate is a collagenous tissue approximately 1 mm thick that
provides rigid support to the eyelid. Tissues that closely re­
semble the tarsus and can be used in its reconstruction in­
clude free tarsoconjunctival grafts from the upper eyelids,
hard palate, cartilage, banked sclera, and acellular collagen
matrices. Tarsoconjunctival grafts are understandably the
ideal tissue for posterior lamellar reconstruction. Vascular­
ized options include the Hughes tarsoconjunctival flap (for
lower lid defects)11 and periosteal flaps (Fig. 55.16). When
considering which graft to use, it is important to ensure that
nonkeratinized tissue is placed along the portion of upper
eyelid that contacts the cornea during the blink. This will
prevent breakdown of the corneal surface that can be pain­
ful and reduce vision.
Fig. 55.14 (a) Medial canthal webbing of the right eye preopera­
tively. (b) After Y-V plasty.
a
b
Fig. 55.15 (a) A full-thickness eyelid defect. (b) After repair with a
semicircular (Tenzel) flap.
a
b
Fig. 55.16 (a) Vascularized posterior lamellar pedicles include the
Hughes tarsoconjunctival flap (arrows). (b) The periosteal flap.
a
b

1035
Chapter 55 Eyelid Reconstruction
plate. Multiple interrupted 5–0 polyglactin sutures are then
passed through both cut ends of the tarsus using a spatu­
lated needle in a horizontal lamellar fashion. It is important
not to pass these sutures full-thickness through the tarsus
and eyelid, because sutures passing through the conjunc­
tiva can abrade the ocular surface and in some cases cause a
corneal abrasion. Three to four passes are used to reapproxi­
mate the upper lid, whereas two passes are sufficient to re­
approximate the lower lid. The silk margin suture is tied off,
followed by the 5–0 polyglactin sutures. The silk suture tails
are left long and anchored to the skin away from the lid mar­
gin at the end of the procedure to prevent rubbing on the
cornea. The lash line can be further reapproximated by an
anterior bite using polyglactin suture. The anterior lamella
is closed with 7–0 polyglactin or 6–0 gut sutures. The silk
sutures are removed in approximately 2 weeks (Fig. 55.18).
fashion. Two vertical incisions are made flanking the notch
and running the vertical length of the tarsus, and the inci­
sions are then tapered to a point to form the apex of a pen­
tagon whose base is the lid margin.
The lid margin is then carefully reapproximated using
4–0 silk suture in a vertical mattress fashion through the
Meibomian glands. This landmark ensures that the stitches
are passed within the substance of the tarsal plate. The su­
ture is tightened after passage to mimic the final appear­
ance when tied. Once this is accomplished, there should be
a mild eversion or “puckering up” of the lid margin so that
the lid margin will be flush once wound healing is complete.
If the margin does not align properly at this stage, this suture
should be removed and passed once again. After realign­
ing the margin, the tarsus is repaired on its anterior face.
The anterior lamella is dissected off the underlying tarsal
Fig. 55.17 Lid margin notching.
Fig. 55.18 Pentagonal wedge resection. (a) Preoperative markings. (b) A chalazion clamp protects the globe and offers hemostasis while
the pentagonal wedge is resected. (c) After excision of the pentagon, the anterior lamella is dissected off the posterior lamella along the
wound edges to expose the tarsal plate. (d) A 4–0 silk suture has been passed in a vertical mattress fashion through the Meibomian gland
orifices and 5–0 polyglactin sutures have been passed in a horizontal lamellar fashion on the body of the tarsal plate. (e) Tightening of the
vertical mattress suture gives a puckered appearance to the margin. (f) The lash line is further supported by passing a 5–0 polyglactin (or
similar) suture. (g) The eyelid margin is well approximated.
a
b
c
d
e
f
g

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1036
flap can be attached to the lateral tarsus to reduce horizon­
tal tension on the lid while ensuring an adequate attach­
ment to the lateral orbital rim (Fig. 55.19).
In mild cases of eyelid retraction with normal horizon­
tal laxity, a transconjunctival incision can be performed
beneath the inferior tarsal border to transect the lower lid
­retractors (Fig. 55.20). If needed, this incision can be carried
down deeply using Bovie cautery to release any scar tissue
tethering the lower lid retractors to the inferior orbital rim.
A superior traction suture (Frost suture) can be placed to al­
low the transected lower lid retractors to heal in a recessed
position. An alternate technique involves directly recessing
the lower lid retractors by suturing the inferior cut edge of
the conjunctiva to the postorbicularis fascia several millime­
ters below the inferior border of the tarsus with a running
6–0 fast-absorbing gut suture.
When there is concomitant horizontal lid laxity, a lat­
eral tarsal strip procedure can also help elevate the lower
lid. After the strip is fashioned and the lid shortened, 4–0
Lower Eyelid Retraction
Eyelid retraction describes the condition in which the eyelid
is pulled open too far and causes excessive exposure of the
ocular surface. In isolated lid retraction, the lid is neither
turned in (entropic) nor turned out (ectropic) with respect
to the globe, although lid retraction can certainly present
in conjunction with other lid malpositions. The common
causes of lower eyelid retraction include middle lamellar
scarring because of excessive cautery of the orbital sep­
tum and lower lid retractors and improper wound closure
that incorporates or tethers the orbital septum or lower lid
retractors. Another important cause of lower eyelid retrac­
tion results from excessive horizontal tension on the pos­
terior lamella from aggressive primary closure. In these
patients, the examination will disclose a very tight eyelid,
and a lateral canthotomy and inferior cantholysis can re­
lieve this excessive tension. Alternatively, after performing
a canthotomy, a posterior lamellar substitute or periosteal
Fig. 55.19 Augmentation of the horizontal dimension of a
posterior lamellar graft that is too narrow (a Hughes flap
in this case) using acellular collagen matrix (arrow) allows
for anchoring of the lateral canthus and prevents the eyelid
from being too tight.
Fig. 55.20 (a) Release of the lower lid retractors starts by everting the lower lid margin with a Frost suture. (b) The conjunctiva is incised at
the base of the tarsal plate. (c) The lower lid retractors can be seen as a thicker white band and are separated from the conjunctiva (arrows).
a
b
c
a
b
Fig. 55.21 Lower lid retraction repair using multiple approaches. Before
(a) and after (b) bilateral canthopexy, suborbicularis oculi fat (SOOF)
lift, and placement of a posterior lamellar spacer graft. (c) Placement
of a posterior lamellar spacer graft using acellular collagen matrix in
another patient.
c

1037
Chapter 55 Eyelid Reconstruction
side by shorter posterior lamellar grafts (e.g., hard pal­
ate, acellular collagen matrix), creating a composite graft
that reapproximates the medial and lateral canthal at­
tachments. The levator aponeurosis is then secured to the
anterior face of this graft, approximately 2 mm below the
superior border.
Upper eyelid retraction can also occur after perform­
ing a second stage Hughes procedure. This results from in­
complete dissection of the conjunctival flap during the first
stage. Either the dissection was not carried high enough,
resulting in excessive vertical tension on the flap, or Mül­
ler’s muscle was not adequately dissected off the conjunc­
tiva of the flap. Excessive cautery during this dissection
should be avoided, because this can also precipitate eyelid
retraction.
If eyelid retraction is noted as a late complication of re­
construction, the surgeon can adjust the height of the eyelid
in a variety of ways. One approach involves performing a lid
crease incision, locating the superior border of the tarsus,
and then directly dissecting off and recessing the levator
aponeurosis from its attachment to the tarsal plate. An alter­
nate approach involves creating a full-thickness blepharot­
omy incision through the eyelid. In this method, a shoehorn
is applied to the undersurface of the eyelid. A no. 15 blade
is used to perform a lid crease incision. Dissection is carried
through the orbicularis muscle until the superior border of
the tarsal plate is identified. A no. 15 blade is then used to
complete the incision through the levator aponeurosis, Mül­
ler’s muscle, and conjunctiva until the metal from the shoe­
horn protector is visible. This confirms that a full-thickness
blepharotomy has been achieved and prevents inadvertent
injury to the globe. The shoehorn can be removed periodi­
cally and the patient placed in an upright, seated position
to evaluate the eyelid position. The blepharotomy can be
extended medially and laterally until the desired height and
contour have been achieved. The skin is then closed with
6–0 plain gut in an interrupted fashion and 6–0 fast absorb­
ing gut suture in a running fashion (Fig. 55.22).
polyglac­tin sutures are used to anchor the strip to the peri­
osteum just inside the lateral orbital rim. In addition, when
there is significant midface laxity that can be effectively
used to support the lower lid, the orbitomalar ligament can
be released at the level of the periosteum. The SOOF can be
mobilized with a 5–0 polyglactin suture and suspended to
the periosteum just external to the lateral orbital rim, result­
ing in improved support for the lower lid.
In severe cases of lid retraction, a lid spacer graft (e.g.,
free tarsoconjunctival graft, hard palate, autogenous der­
mis, or acellular collagen matrices) can be used to bridge
the lower lid retractors and the inferior border of the tarsus,
thereby elevating the lower lid. The graft is fashioned to be
at least 5 mm in vertical height and span the entire length
of the eyelid. The superior portion of the graft is attached to
the inferior border of the tarsal plate, and the inferior por­
tion of the graft is attached to the lower lid retractors and
conjunctiva using 7–0 polyglactin suture or 6–0 gut suture
in an interrupted or running fashion (Fig. 55.21). Finally, a
4–0 silk Frost suture can be placed through the lid margin
to put the lower lid on superior traction for approximately
1 week.
Upper Eyelid Retraction
Causes of upper eyelid retraction are somewhat analogous
to those of the lower eyelid but with a few subtle differ­
ences. An important component of upper eyelid posterior
lamellar reconstruction is the height. The upper eyelid tar­
sal plate is 2.5 to 3 times the vertical height of the lower
eyelid tarsal plate. Attaching the levator aponeurosis to a
vertically shortened tarsus will result in retraction. Con­
structing a 10- to 12-mm posterior lamellar graft centrally
is key to restoring this anatomic relationship and prevent­
ing this complication. It is also important to ensure that
this central graft is covered by conjunctiva (e.g., free tarsal
graft). Anything else will débride the corneal epithelium
with each blink. This central flap can be flanked on either
Fig. 55.22 (a) Subtle right upper eyelid retraction. (b) A shoehorn corneal protector is placed under the lid while the levator aponeurosis,
Müller muscle, and conjunctiva are transected, completing the blepharotomy (arrows). (c) Postoperative result.
b
a
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1038
the skin just adjacent to the lash line away from the lid mar­
gin. Up to three sets of horizontal mattress sutures can be
passed across the length of the eyelid, depending on the ex­
tent of involvement. The sutures are tied under an appro­
priate degree of tension to rotate the lid margin into a good
position. The skin is then closed with 6–0 fast-absorbing gut
suture (Fig. 55.23).
Red Eyelid Margin
After reconstruction the eyelid can sometimes take on a red
appearance at the eyelid margin. Posterior lamellar grafts,
specifically hard palate grafts and tarsal plate grafts that
are oversized, not well covered by anterior lamella, or not
in contact with the tear meniscus, can undergo squamous
metaplasia and become keratinized (Fig. 55.24). This can
also occur after a second stage Hughes procedure when the
conjunctival pedicle is released and the eyelid is opened.
This manifests as a thick, red lid margin. Prevention in­
volves slightly overcorrecting the vertical anterior lamellar
deficiency. In addition, securing the posterior lamellar graft
firmly to the eyelid retractors and tightening the lateral can­
thus until adequate horizontal tension is achieved will aid in
ensuring that the eyelid is well approximated to the globe.
Precautions the surgeon can take in the setting of a second
stage Hughes procedure include maintaining the scissors
parallel to the eyelid margin when releasing the flap.
Mild cases can be managed by aggressive lubrication
with ophthalmic ointments. Surgical management differs
depending on the cause. Red eyelid margins from cicatri­
cial ectropion will need to undergo surgery to release the
cicatrix and augment the vertical component of the ante­
rior lamella.
Cicatricial Entropion from Posterior
Lamellar Scarring
Cicatricial entropion in the setting of eyelid reconstruction
can occur from excessive cauterization and shrinkage of
the conjunctiva (the posterior lamella) or from improper
closure of transconjunctival incisions that shortens the
posterior lamella. When evaluating entropion, the sur­
geon should also evaluate for trichiasis, or the rubbing of
eyelashes on the cornea and ocular surface. Trichiasis can
not only cause tearing, pain, and ocular foreign body sensa­
tion but can also cause corneal abrasions, infections, and
decreased vision. When there are only a few misdirected
eyelashes, focal treatments include manual epilation for
transient relief versus more permanent options such as
cryotherapy, hyfrecation, or trephination of the lash fol­
licles using a lacrimal trephine.
In most cases of cicatricial entropion, a lid margin rota­
tional procedure is sufficient to address the entropion and
trichiasis. One effective method for rotating the lid margin is
the Wies procedure, which involves performing a transverse
blepharotomy with rotation of the eyelid.12 The procedure
can be performed on the upper or lower eyelid. A chala­
zion clamp is applied with the opening facing anteriorly to
help with hemostasis and prevent inadvertent globe injury.
A full-thickness blepharotomy is made 4 mm from the lower
lid margin (or about 2–3 mm from the upper lid margin)
using a no. 15 blade and sharp Westcott scissors for the ex­
tent of the lid that is involved. The lid margin is then rotated
by placing a double-armed 6–0 polyglactin suture through
lower lid retractors (in the lower lid) or the anterior sub­
stance of the tarsus (in the upper lid). The two needles are
then passed in a pretarsal plane and externalized through
Fig. 55.23 (a) Cicatricial entropion after transconjunctival orbital fracture repair after lower lid margin rotation (Wies procedure) (b).
(c) Cryotherapy to the upper lid, shown in a different patient, is an effective method for destroying lash follicles (two freeze-thaw cycles
with approximately 30 to 40 seconds of freeze in each cycle).
a
b
c
Fig. 55.24 Red eyelid margin after cicatrization of skin graft causing
ectropion.

1039
Chapter 55 Eyelid Reconstruction
lysis using Westcott scissors. If there is significant lower lid
laxity, the lower lid can be shortened horizontally by excis­
ing a full-thickness triangle of the lower lid. The lateral can­
thal angle can be reformed with a sharp angle using a 7–0
polyglactin suture passed through the grey line of the upper
and lower lids. An additional one or two 5–0 polyglactin su­
tures can be used to reapproximate the lateral tarsus to the
superior crus of the lateral canthal tendon. The skin is then
closed with multiple interrupted fast-absorbing gut sutures.
Avoiding Complications in the Tear
Drainage System
Repairing Tear Drainage System Defects
Tearing can be caused by numerous pathologies involv­
ing the ocular surface, lids, lashes, or nasolacrimal drain­
age apparatus. Tearing that begins after eyelid trauma or
reconstruction can be caused by transection of the upper,
lower, and/or common canaliculus without proper stenting
and repair. Many patients can tolerate obstruction of one
canaliculus without symptomatic tearing, but in symptom­
atic cases, a surgical evaluation is warranted. Careful atten­
tion should be paid to the portion of the eyelids medial to
the puncta in which the canaliculi run. Small lacerations in
the tear drainage system can be repaired through stenting
procedures (Fig. 55.26). Defects in which portions of the
canaliculus have been removed warrant more definitive
surgery in the future through creation of a drainage system
that bypasses the canalicular mucosa.
Damage to the tear drainage system can also be inadver­
tently created during reconstruction. The canalicular system
is fairly superficial at the level of the medial canthus. Care
must be taken to avoid deep dissection during the repair of
anterior lamellar defects in this region or in performing me­
dial canthal tendon plication.
Lateral Canthal Dystopia
Lateral canthal dystopia, which includes rounding of the
lateral canthal angle or disinsertion of the lateral canthal
tendon, can occur after reconstructions involving the can­
thus and lateral portion of the eyelid. The evaluation of lat­
eral canthal dystopia should focus on the sharpness of the
angle, the position of the lateral canthus with respect to the
medial canthus, and whether there is horizontal lid laxity,
lateral canthal tendon disinsertion, or both (Fig. 55.25).
In the setting of a rounded lateral canthus caused by
disinsertion of the lateral canthal tendon without horizon­
tal lid laxity, a “canthus-sparing canthoplasty” (e.g., lateral
canthal tendon plication) can be performed. A no. 15 blade
is used to incise the skin and orbicularis from just lateral
to the canthal angle and extending approximately 10 mm
in length laterally. Dissection is carried down to the lateral
orbital rim using Bovie cautery. A 4–0 Vicryl suture on a
P-2 needle is used to engage the superior crus and then the
inferior crus of the lateral canthal tendon in a whipstitch
fashion. The needle is then passed through the periosteum
just inside the lateral orbital rim, making sure that the lids
are well approximated and not distracted from the globe.
A variation of this technique can be performed using a drill
hole through the lateral orbital rim, and the hole or holes
are used as an extremely stable anchor point through which
the suture can be passed and the tendon supported. The
sideways-V configuration of the lateral canthus is restored.
Note that the attachments to the lateral canthus should be
approximately 2 mm above that of the medial canthus for
the eyelid in individuals of European descent. The skin is
then closed using multiple interrupted 6–0 fast-absorbing
gut sutures.
If the lateral canthal tendon is intact but there is round­
ing of the canthus because of a suboptimal canthal angle
reconstruction or dehiscence, the lateral canthus can be re­
constructed with a lateral canthotomy and inferior cantho­
Fig. 55.25 Lateral canthal tendon dystopia. (a) Rounding of the canthal angle, pseudo–eyelid retraction, and horizontal fissure narrowing
are features of lateral canthal tendon disinsertion. (b) This alters the blink dynamic and can lead to lagophthalmos. (c) Lateral canthal ten­
don disinsertion. (d) The same patient, immediately after lateral canthal tendon plication with drill holes.
a
b
c
d

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1040
tiva into the nose. As in the case of a standard dacryocys­
torhinostomy (DCR), bone is removed from the lacrimal sac
fossa, and the lacrimal sac is marsupialized to allow drainage
directly into the nose beneath the middle turbinate. A min­
ute glass funnel-shaped Jones tube is then placed within this
tract and is left in place indefinitely (Fig. 55.27). The tube
may occasionally need replacement or repositioning over
time. Postponing this surgery until the surgeon is comfort­
able that there is no evidence of recurrent malignancy is a
practical approach that aids in regional control of recurrent
disease, because these bones are excellent anatomic barriers
from spread within the nasal cavity.
Other Complications
Retrobulbar Hemorrhage
Retrobulbar hemorrhage is one of the most devastating
complications of oculoplastic surgery. The eyelids and
orbit are extremely vascular structures, and a space-oc­
cupying hematoma within the fixed bony orbit can result
in a vision-threatening orbital compartment syndrome.
Excessive elevation in orbital pressure particularly at the
orbital apex can result in compression of the optic nerve,
restricted retinal perfusion through the central retinal ar­
tery, and permanent vision loss. Prompt recognition and
management of a retrobulbar hemorrhage is essential be­
cause of the limited window of time before irreversible vi­
sion loss occurs. Clinically, a retrobulbar hemorrhage can
manifest rapidly or slowly over the course of several hours
and is characterized by diffuse eyelid ecchymosis, subcon­
junctival hemorrhage, massive proptosis with restricted
extraocular motility, decreased vision, elevated intraocu­
lar pressure, pain, and a relative afferent pupillary defect.
Emergent ophthalmologic consultation is indicated, and
Tearing Caused by Canalicular Obstruction
Canalicular obstructions can be diagnosed on exam by
probing and irrigation of the canaliculus using a lacrimal
irrigation cannula or Bowman probe. A canalicular obstruc­
tion will result in a “soft stop” upon probing that occurs
proximal to the lacrimal sac. The canalicular obstruction
prevents encountering the usual “hard stop” that occurs
when the probe contacts the bone of the lacrimal sac fossa.
Irrigation against a canalicular obstruction will result in
complete reflux through the same punctum through which
the irrigation cannula is inserted (as opposed to passage
down the nose and throat, or reflux through the opposing
punctum).
In cases of focal canalicular obstruction without mis­
alignment of the proximal and distal segments, a lacrimal
trephine can be passed along the canaliculus to remove the
scar tissue within the lumen of the canaliculus.
After eyelid reconstruction or trauma, canalicular ob­
structions more commonly involve misalignment of the can­
alicular segments proximal and distal to the obstruction. In
this scenario, the canaliculus can be transected distal to the
obstruction, revealing the patent lumen of the distal cana­
licular segment. If feasible, the distal end can be stented. A
monocanalicular or bicanalicular stent can be inserted to
allow the canaliculus to heal around the stent without re­
currence of obstruction. Stents are typically left in place for
6 to 12 weeks and can be removed in the clinic.
Creation of a bypass tract in the form of a conjunctivo­
dacryocystorhinostomy (CDCR) with Jones tube is indicated
if the obstruction occurs near the common canaliculus (i.e.,
far from the punctum), if the patient has upper and lower
canalicular obstruction, or if a significant portion of the can­
alicular system was resected. This surgery involves creating
a fistulous tract for tears to drain from the medial conjunc­
Fig. 55.26 (a) Canalicular laceration. The arrow points to the punctum. (b) The lateral portion of the canaliculus was cannulated with a 00
Bowman probe. The laceration was repaired using a donut silicone stent through the upper canaliculus. (c) The stent is seen adjacent to
the medial canthus and can be removed 3 months after surgery.
a
b
c
Fig. 55.27 Conjunctivodacryocystorhinostomy with a Jones tube. The tube is inconspicuously positioned in the right caruncle (arrow).

1041
Chapter 55 Eyelid Reconstruction
agents with local anesthetic, and meticulous hemostasis
were discussed earlier as preoperative measures the sur­
geon can take to prevent retrobulbar hemorrhage. Patients
should also be instructed to avoid strenuous activity, heavy
lifting, bending, and anything associated with the Valsalva
maneuver.
Conclusion
This chapter describes the basic skills to handle the majority
of complications that may arise after eyelid reconstruction.
The importance of understanding the underlying anatomy
and physiology of the eyelids becomes paramount, because
the structures in the eyelid are dependent on one another
for fluid function. This understanding allows for anticipa­
tion of potential complications that can be avoided through
meticulous planning and technique. In cases of complex
eyelid defects, reconstructions can be performed in con­
junction with an oculofacial plastic surgeon.
management options include performing a definitive lat­
eral canthotomy and inferior cantholysis, topical and sys­
temic medications to reduce intraocular pressure, bony
decompression of the orbit, and in recent postoperative
situations, evacuation of the hematoma and cautery of the
bleeding vessel (Fig. 55.28).
The importance of preoperative suspension of anti­
platelet agents and anticoagulants, use of vasoconstricting
Fig. 55.28 Retrobulbar hemor­
rhage.
References
1. Codner MA, McCord CD. Eyelid & Periorbital Surgery. 2 ed.
St Louis: Thieme Medical Publishers; 2016
2. Leibovitch I, Huilgol SC, Hsuan JD, Selva D. Incidence of
host site complications in periocular full thickness skin
grafts. Br J Ophthalmol 2005;89(2):219–222
3. Kim HJ, Hayek B, Nasser Q, Esmaeli B. Viability of full-
thickness skin grafts used for correction of cicatricial ec­
tropion of lower eyelid in previously irradiated field in the
periocular region. Head Neck 2013;35(1):103–108
4. Rathore DS, Chickadasarahilli S, Crossman R, Mehta P, Ah­
luwalia HS. Full thickness skin grafts in periocular recon­
structions: long-term outcomes. Ophthal Plast Reconstr
Surg 2014;30(6):517–520
5. Fitzpatrick
RE.
Treatment
of
inflamed
hypertro­
phic scars using intralesional 5-FU. Dermatol Surg
1999;25(3):224–232
6. Darougheh A, Asilian A, Shariati F. Intralesional triam­
cinolone alone or in combination with 5-fluorouracil for
the treatment of keloid and hypertrophic scars. Clin Exp
Dermatol 2009;34(2):219–223
7. Samimi DB, Alabiad CR, Tse DT. An anatomically based ap­
proach to intralesional corticosteroid injection for eyelid
capillary hemangiomas. Ophthalmic Surg Lasers Imaging
2012;43(3):190–195
8. Sobanko JF, Vachiramon V, Rattanaumpawan P, Miller CJ.
Early postoperative single treatment ablative fractional
lasing of Mohs micrographic surgery facial scars: a split-
scar, evaluator-blinded study. Lasers Surg Med 2015;47(1):
1–5
9. Cavalié M, Sillard L, Montaudié H, Bahadoran P, Lacour
JP, Passeron T. Treatment of keloids with laser-assisted
topical steroid delivery: a retrospective study of 23 cases.
Dermatol Ther (Heidelb) 2015;28(2):74–78
10. Tenzel RR, Stewart WB. Eyelid reconstruction by
the
semicircle
flap
technique.
Ophthalmology
1978;85(11):1164–1169
11. Hughes WL. A new method for rebuilding a lower lid: Re­
port of a case. Arch Ophthalmol 1937;17:1009–1017
12. Wies FA. Surgical management of entropion. J Int Surg
1954;21:758–760
Discussion by Michael Patipa
After 35 years of oculoplastic surgery, I would suggest
several pearls that may help reconstructive surgeons.
In addition, there are typically multiple alternative
methods to address a surgical problem. This discussion
shares some of my alternative techniques to problems
encountered by reconstructive surgeons.
Preoperative Considerations
The temporal branch of the facial nerve innervates and
supplies the lateral brow, and the zygomatic branch
courses under the lower lid, up the medial canthal an­
gle, to innervate the corrugators. This is why a patient
with medial canthal defects or lacrimal dacryocystorhi­
nostomy may have transient difficulty closing the me­
dial upper eyelid. This commonly improves with time.
The surgeon should always take a photo of the de­
fect before undertaking reconstruction. This is the best
way to help the patient appreciate the defect caused by
the cancer and have realistic expectations after surgery.
I always have patients referred with a post-Mohs de­
fect look at the defect in the preoperative arena. If they

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1042
refuse, I tell them I will not operate on them. I explain to
them that this was their cancer, their defect, and I will
work with them as their teammate to make the result as
good as possible. I am a surgeon, not a magician, and it
is a scalpel, not a magic wand. Most patients appreciate
this discussion and agree to look at their defect and dis­
cuss the anticipated proposed reconstructive technique.
In the operating room, I always have photos taken of
the defect. If a patient is angry or upset in the postopera­
tive course, I show them and give them a printed copy
of the defect they started with. Again, this frequently
subdues their anger or impatience for healing.
When discussing with the patient the priorities in
their care, I explain the goals:
1. Get rid of the malignancy
2. Put the eyelid back so it can function properly pro­
tecting the globe
3. Obtain the best possible aesthetic outcome
We try to achieve all three goals, but in that priority
order.
Surgical Considerations
Radiation and exenteration of the total orbital contents
can be described as more extensive treatments in in­
curable disease. Another option is vismodegib, an agent
that may shrink the tumor (one 150 mg capsule taken
orally until disease progression or until unacceptable
toxicity).
If the entire upper or lower tarsal plate or eyelid is
lost to surgery, some surgeons may reattach the eyelid
retractors. I disagree with this course, because it may
cause retraction. Reconstructing the upper eyelid with
a contralateral tarsal conjunctiva graft or the lower eye­
lid with hard palate, tarsus conjunctiva, or Alloderm and
suturing the remaining conjunctiva to the superior or
inferior edge of the graft will adequately reconstruct the
posterior lamella. For skin grafts, I suggest the preau­
ricular skin, which is an excellent donor site.
As previously mentioned, virtually all patients with
lateral canthal tendon laxity need the lateral canthal ten­
don tightened. My technique is a lateral canthotomy: re­
section of 0 to 2 mm of the lax lateral canthal tendon and
reattachment of the lateral tarsus to the lateral orbital
rim. I never resect full-thickness lateral eyelid; this tech­
nique tightens the lid back to its normal anatomic posi­
tion (Video 55D.1). I use a Frost suture for all patients
who have lower eyelid surgery, whether reconstructive
or cosmetic. I use a 5–0 Prolene placed in a double-armed
fashion through a bolster, then through the skin coming
out the lower eyelid gray line and sutured to the fore­
head laterally or glabella medially and tied over a cotton
bolster. The bolsters keep the suture from burying in the
skin. The Frost suture generally remains for 6 to 7 days
(Fig. 55D.1).
I am a big advocate of flaps over grafts and use cheek
flaps for anterior lamellar defects on most lid or cheek
defects. These anterior lamellar defects always require
a lateral canthal tendon tightening behind the skin–­
muscle flap. Medial defects are generally closed with
glabellar flaps. Virtually all of these cases, whether
central skin–muscle or medial defects, require a Frost
­suture. A Frost suture has a better postoperative appear­
ance and more rapid recovery after surgery.
In the treatment of neurogenic ectropion from fa­
cial nerve palsy, lower lid tightening in conjunction with
malar fat pad elevation is successful in most cases. With
a very flaccid lid that requires vertical support, this is
the only time I use ear cartilage graft rather than hard
palate for vertical support.
Posterior lamellar defects either involve exclusively
posterior lamellar (i.e., conjunctival or conjunctival–eye­
lid retractor) defects or full-thickness eyelid defects. The
former are very rare and thus are not addressed here.
Full-thickness eyelid defects requiring reconstruction
are relatively common. Some surgeons advocate reat­
taching the upper eyelid (levator aponeurosis) or lower
eyelid retractors in the reconstruction. I have not found
this to be necessary. When reconstructing a horizontal
full-thickness eyelid margin defect, reconstructing the
lid margin defect automatically reconstructs the retrac­
tors. When reconstructing large full-thickness defects
requiring posterior lamella replacement with autografts
such as tarsus conjunctiva or mucosal grafts, reattaching
the conjunctiva superiorly or inferiorly, then reattach­
ing the lateral and medial ends of the posterior lamella
graft and reconstructing the anterior lamella, will recon­
struct the eyelid satisfactorily. Of note, hard palate grafts
should not be used in upper eyelid reconstructions, be­
cause they would be abrasive to the cornea.
The use of Hughes tarsoconjunctival flaps is one
option for large lower eyelid defects. This procedure
requires a second stage to open the flap and a second
donor site such as a full-thickness skin graft for the
anterior lamella and commonly results in a red eyelid
margin when the reconstruction is completed. I use a
Fig. 55D.1 A Frost suture of 5–0 Prolene on a bolster.

1043
Chapter 55 Eyelid Reconstruction
laterally based tarsus conjunctiva flap whenever the lat­
eral canthus has been lost to tumor resection or there
is a large lower eyelid full-thickness defect; I then use
a skin–muscle flap also based laterally for the anterior
lamella. It is critical to leave 3.5 to 4 mm of distal tarsus
conjunctiva from the upper lid donor site to prevent an
upper eyelid entropion caused by inadequate upper eye­
lid tarsus support (Fig. 55D.2).
In regard to complications in posterior lamellar re­
constructions, I have found that an early minimal eyelid
margin notch and even full-thickness lid reconstruction
defects will heal on their own in 6 weeks without surgi­
cal intervention. Resuturing a dehiscence will inevitably
result in a repeat dehiscence. Leaving the lid alone, with
patience and ointment at bedtime, will allow it to heal.
Against all traditional rules of eyelid margin recon­
struction, I have found placing three 5–0 silk sutures
to reconstruct the eyelid margin is very effective. The
sutures are placed through the gray line, lash line, and
mucocutaneous junction posteriorly, and that is all that
is necessary for lid margin reformation. Using just lid
margin closure and then skin closure avoids the need
of closing the tarsus with absorbable sutures and the
occasional infection or inflammation that occurs from
these sutures, particularly if polyglactin sutures with
their prolonged resorption time are used. Additional
5–0 silk sutures are placed to close the skin defect and
then the three lid-margin sutures are tied under one of
the skin sutures to keep them away from the eye. Every
patient I perform lower eyelid surgery on gets a Frost
suture. The suture ensures that the wound will remain
intact, the patient will not touch the reconstruction, and
the patient recognizes that this was a real operation. I
remove the Frost suture 6 days postoperatively and the
remaining sutures 1 week later, 2 weeks after surgery.
The common causes of lower eyelid retraction in­
clude middle lamellar scarring caused by excessive cau­
tery of the orbital septum and lower eyelid retractors
and improper wound closure that incorporates or teth­
ers the orbital septum or lower eyelid retractors. An­
other important cause of lower eyelid retraction results
from horizontal tension on the posterior lamella from
aggressive primary closure. I would propose that an ad­
ditional very important source of lower eyelid retraction
is scarring between the lower eyelid retractors, a mobile
structure, and the orbital septum, a structure fixed to
the inferior orbital rim and anterior maxilla, the origin
of the orbital septum. This scarring between these two
structures immobilizes the lower eyelid retractors and
pulls the retractors inferiorly.1
In severe cases of lower eyelid retraction, whether
caused by scarring after eyelid reconstruction or a com­
plication of cosmetic surgery, I advocate using a hard
palate mucosal graft as a spacer graft. The incision is
made at the inferior tarsus in the lower eyelid with a
transconjunctival approach, the dissection releases
the posterior lower eyelid retractors from the overly­
ing scarred adherent orbital septum until the orbital fat
lies between their two planes, and a 5-mm hard palate
graft is sutured to the inferior tarsus and recessed con­
junctiva, not suturing or advancing the lower eyelid re­
tractors. This allows the retracted lower eyelid to move
superiorly. A Frost suture is placed through the lateral
lower eyelid margin and lateral brow. This permits both
sides to be performed at the same time if necessary.
Fig. 55D.2 (a) A full-thickness eyelid defect after basal cell carcinoma excision. (b) A tarsus conjuctiva laterally based flap recon­
structs the posterior lamella. For adequate upper eyelid support after harvesting the graft, 4 mm of tarsus distal to the donor flap
site, to the eyelid margin, must be retained. (c) The flap is rotated into the lower eyelid defect. (d) The skin–muscle flap, outlined
as an upper eyelid blepharoplasty incision, is rotated into the lower eyelid to form the anterior lamella. (e) The Frost suture is
placed. (f) The postoperative result.
a
b
c
d
e
f

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1044
In upper eyelid retraction treatment, I do not su­
ture the levator aponeurosis to the anterior surface of
any graft. I instead place a Frost suture through the up­
per eyelid margin and suture to the cheek over a cotton
bolster, placing the upper eyelid on stretch for a week.
When addressing upper eyelid cicatricial entropion,
it is critical to differentiate entropion from trichiasis.
The former is most commonly caused by insufficient tar­
sus remaining after reconstruction by not leaving 3.5
to 4 mm of tarsus from the lid margin superiorly. Tri­
chiasis is a result of an abnormal eyelid margin, either
in the upper or lower eyelids. Focal misdirected lashes
can be treated with various techniques as discussed in
the chapter. Large areas or total lid margin trichiasis re­
quires resection of the anterior lamella, preferably at the
gray line; resection of the lashes and several millimeters
of anterior lamella skin; and insertion of a full-thickness
buccal mucous membrane graft.
A red eyelid margin can be treated with the Hughes
procedure. I believe, as previously mentioned, a laterally
based tarsus conjunctival flap and anterior lamella re­
placement prevents the problems of a second procedure
and a thick, red lid margin.
For lateral canthal dystopia, I recommend evaluat­
ing lateral canthal mobility, as previously mentioned, to
address the integrity of the lateral canthal tendon. If the
lateral canthus is mobile and improperly positioned, re­
secting the upper and lower limbs of the lateral canthal
tendon and then repositioning them to an appropriate
anatomic location is very effective.
If a retrobulbar hemorrhage requiring intervention
occurs, the surgeon must not hesitate to release the up­
per and lower limbs of the lateral canthal tendon during
the canthotomy and cantholysis.
Postoperative Concerns
Patients commonly complain of excessive tearing after
surgery. I tell them that “at age 40, everything heads
south; at 50, everything dries out; at 60, the glue stops
sticking.” Therefore, around age 50 years, as individu­
als go through menopause and “malopause,” their eyes
will become drier. The body compensates for this phys­
iological phenomenon by imposing upper eyelid ptosis
to reduce the corneal exposure. In addition, the puncta
become stenotic to salvage the diminished tears and
keep the eyes from feeling dry. Any alteration in the lid
position, swelling of the conjunctiva as the lid heals,
or other alteration of the normal protective position­
ing and function of the eyelids can produce tearing and
foreign body sensation. The lower eyelid is basically
held up by the lateral and medial canthal tendons or
ligaments. The medial is difficult to surgically access,
but the lateral is very easy to surgically access. The lat­
eral canthal angle is positioned 2 mm higher than the
medial canthal angle so the tears flow downhill to the
lacrimal outflow system.
The snap-back and eyelid distraction test are two
common tests mentioned in the chapter. I would also
strongly recommend the lateral canthal angle mobility
test. The surgeon pulls the lower lid down with a finger,
and if the lateral canthal angle moves, the lateral canthal
tendon is lax and will need to be tightened in the recon­
structive procedure to prevent lower lid descent with a
resulting ectropion and/or retraction.1
Conclusion
There are always variations on surgical techniques, and
I have offered several based on my experience. Skin–
muscle flaps are preferable to skin grafts. Lateral can­
thal tendon tightening will significantly prevent lower
eyelid retraction and protect the cornea. A Frost suture
is an immense benefit in preventing complications,
providing patient comfort, and accelerating the post-
operative recovery.
Reference
1. Patipa M. The evaluation and management of lower
eyelid retraction following cosmetic surgery. Plast Re­
constr Surg 2000;1062:438–453, discussion 454–459

1045

Facial Reanimation Surgery
Eyal Gur and Daniel Josef Kedar
Paralysis of the facial mimetic muscles causes loss of vol­
untary facial movements, loss of involuntary facial ex­
pression, and dysfunction in facial tone. It is a devastating
condition with profound functional, aesthetic, and psy­
chological consequences. Symptoms may include ocular
dryness and tearing, speech difficulties, oral incontinence,
impairment in mastication, and obstruction of the nasal
airway. Significant emotional distress is the result of facial
disfigurement, impaired communication, and social dys­
function.
Facial paralysis manifests as a spectrum of conditions,
either unilateral or bilateral, that range from partial to com­
plete weakness. It may be congenital or acquired; acquired
conditions include neoplasms, trauma, infection, and iatro­
genic and idiopathic causes.
Reanimation of the paralyzed face focuses on restora­
tion of form and function. Goals are to achieve protection of
the eye, facial symmetry at rest, and voluntary symmetrical
facial movement and to restore involuntary mimetic facial
expression.1
Reconstructive Considerations
The most significant unit for reconstruction, from a func­
tional and aesthetic perspective, is the buccal–zygomatic
muscle complex (BZMC), responsible for smiling and for
the tone of the cheeks. This complex includes the riso­
rius, the zygomaticus major and minor, and the levator
anguli oris muscles and is normally innervated by tribu­
taries of the zygomatic and buccal branches of the facial
nerve. Significant functional problems are associated
with paralysis of the oral musculature, including drool­
ing and speech difficulties. A flaccid lip and cheek can
lead to difficulties with chewing food, cheek biting, and
pocketing food in the buccal sulcus. However, the main
emphasis of surgery is usually centered on reconstruc­
tion of a smile.
Three elements are required for the formation of a smile:
1. Neural input
2. A functioning muscle innervated by the nerve
3. A proper muscle orientation
All three factors contribute to the determination of which
reconstruction would be ideal.
Reconstructive modalities in dynamic reanimation can
be classified by two basic criteria:
1. Whether reconstruction is based on the facial nerve or
on a different cranial nerve2
2. Whether the working muscle unit is the original BZMC
or a transferred muscle flap3
Facial nerve–based reanimation can be based on an ipsilat­
eral facial nerve, depending on the presence of a functional
branch or stump. Duration of paralysis is the principal de­
terminant for the need for muscle transfer. If duration is
less than a year, the BZMC is assumed to be viable. Facial
muscles become irreversibly atrophic or too weak to work
properly by 24 months. After this point muscle transfer is
indicated.1
Primary facial nerve repair is possible in cases of recent
trauma to the facial nerve. If there is a large gap between
the proximal and distal nerve stumps, a sural cable nerve
graft is used to interconnect between the stumps of the zy­
gomatic–buccal facial branches with an ipsilateral trunk of
the facial nerve.1
In case of recent paralysis in which a functional facial
nerve branch is available only on the contralateral face, a
cross-face nerve graft is used to relay facial nerve input
across the face to the BZMC. Axons from the contralateral
facial nerve regenerate through the sheath of the graft. They
innervate the muscle over 4 to 6 months.3–5 Because muscle
atrophy can develop while the facial nerve regenerates, an
CHAPTER
56

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1046
Nerve to gracilis
Paralyzed side
Normal side
Vascular anastomosis
Contralateral facial nerve
Cross-face nerve graft
Gracilis flap
Fig. 56.1 Two-stage cross-face nerve graft and free gracilis muscle transfer.
Nerve to gracilis
Gracilis flap
Vascular anastomosis
Masseter nerve
Masseter muscle
Paralyzed side
Normal side
Fig. 56.2 One-stage gracilis muscle transfer to motor nerve to masseter.

1047
Chapter 56 Facial Reanimation Surgery
as teeth clenching. These efforts may become more natural
over time. In this procedure there is no donor nerve mor­
bidity (Fig. 56.2).
Patients who are unsuitable or do not wish to undergo
a microsurgical procedure may be reconstructed by trans­
fer of a local muscle flap, namely the temporalis or masseter
muscles.8 The temporalis muscle procedure usually achieves
fair static and dynamic results. However, it does not provide
spontaneous smile.
Avoiding Unfavorable Results
and Complications in Facial
Paralysis Reconstruction
Summary Box
Unfavorable Results and Complications
in Facial Paralysis Reconstruction
•• Functional damage to the facial nerve on the
normal side
•• Weak contraction and poor smile on the
paralyzed side
•• Worsened state of paralysis
•• Adhesion between skin and transferred muscle
•• Deficient transverse smile motion
•• Bulky cheek
•• Pronounced facial asymmetry
•• Unaesthetic muscle tension
•• Failure to fixate the upper lip muscle
•• Asymmetrical smile action
•• Inability to spontaneously operate the muscle
and smile
•• Inability to create total symmetry in bilateral
facial paralysis
•• Postoperative complications
○
○Bleeding
○
○Infection
○
○Thrombosis
○
○Vascular compromise to muscle flap
○
○Incorrect muscle positioning
○
○Excess bulk
Preoperative Planning and Patient
Selection
During the preoperative planning, the plastic surgeon
must remember that facial paralysis patients present with
a broad spectrum of signs and symptoms. Thus treatment
ipsilateral motor nerve can be transposed to serve as a tem­
porary innervator (“babysitter”) to the muscle. Thus muscle
tone is preserved while waiting for the cross-face grafts to
grow across, and spontaneous smiling is restored.1,6 At the
first surgery two nerve grafts are connected to the upper
and lower trunks of the normal contralateral facial nerve.
Then they are tunneled across the face through the upper lip.
These nerves are banked in the paralyzed pretemporal re­
gion and marked or immediately connected to selected cor­
responding branches. At that same procedure, a short nerve
cable graft is used to connect the nerve to the masseter with
the distal stump of the affected facial nerve. Within 2 to 3
months the paralyzed muscle will regain tone and then will
begin to function in a mass pattern motion. Sometimes at
the same procedure or about 6 to 9 months after the ini­
tial procedure,5 at a second surgery, the paralyzed side will
be reoperated. The two cross-face nerve grafts that were
banked are identified, split into fascicles, and connected to
the facial nerve branches distal to the prior masseter–fa­
cial nerve repair. Within 3 to 6 months spontaneous facial
nerve motion is initiated by the contralateral facial nerve
that should take control of the motion. If the masseter nerve
action is still noticeable and unsightly, the master branch
can be transected.
Facial nerve–based reanimation for long-lasting paraly­
sis necessitates both reinnervation and muscle transfer. Vari­
ous muscles are available for muscle transfer. However, the
gracilis muscle is preferable. The neuromuscular pedicle is
reliable and relatively easy to prepare. A segment of mus­
cle can be cut to any desired size based on the neurovas­
cular pedicle, thereby making the flap customizable to the
patient’s facial proportions. There is no functional loss in
the leg, and the scar is reasonably well hidden7 (Fig. 56.1).
When an ipsilateral nerve is available, a one-stage free
gracilis muscle flap transfer is performed. The flap is inset
subcutaneously in the paralyzed cheek from the modiolus
to the temporal fascia above the auricle. The blood vessels
of the flap are anastomosed to facial or superficial tempo­
ral vessels and its motor nerve is sutured to the ipsilateral
facial nerve zygomatic branch. When an ipsilateral nerve is
unavailable, a two-stage cross-face sural nerve graft and free
gracilis muscle transfer is fabricated. In the first stage, the
nerve graft is harvested, anastomosed to a contralateral fa­
cial branch responsible for smiling stimulus, tunneled across
the face to the paralyzed side, and banked in the upper buc­
cal sulcus. In the second stage (which is scheduled 9 months
later) the free gracilis is transferred and the motor nerve is
sutured to the cable graft that was banked. Reanimation of
the muscle commences after 4 to 8 months. It reaches full
capacity within a year.3,4
When facial nerves are absent on both sides or the pa­
tient is older than 60 years of age and nerve growth is im­
paired, a non–facial nerve reanimation is performed based
on the ipsilateral motor nerve to the masseter nerve that is
connected to a free muscle transfer. Thus the stimulus to
create smiling movement depends on voluntary actions such

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1048
reconstruction modality. For example, if a resection of an
acoustic neuroma resulted in incomplete facial paralysis, the
reconstructive surgeon should communicate with the neu­
rosurgeon to determine whether the tumor was completely
resected and thus whether it may grow back, in which case
the ipsilateral facial nerve should not be used as a source
for reinnervation, because it may cease to function if the
tumor recurs or a secondary procedure is performed on the
neuroma.
Another example is a patient who had a facial trauma
with deep lacerations across the facial nerve anatomy. The
surgeon must be able to determine whether there was a
concomitant fracture to the base of the skull, which could
result in facial nerve injury in and of itself, and thus repair­
ing the nerve at a peripheral location would not improve
the paralysis.
Errors Resulting from Improper Physical
Examination
Physical examination should include the brow motion, the
eye, the nasal airway, the mouth, and surrounding struc­
tures.
The brow’s position should be noted at rest and move­
ment. Visual acuity in each eye should be documented. The
height of the palpebral aperture should be measured and
compared with the normal side. The degree of lagophthal­
mos and the presence of a Bell’s reflex will indicate the risk
of corneal exposure. The lower eyelid position should be
measured and the tone of the lower eyelid should be as­
sessed by the snap test and the position of the inferior cana­
liculi punctum. In addition, the patient should be examined
for corneal irritation or ulceration.
The nasal airway is assessed by forced inspiration. A col­
lapsed nostril and drooping of the cheek represent loss of
muscle tone.
Philtrum deviation, the presence or absence of a nasola­
bial fold, the amount of commissure depression and devia­
tion, the degree to which the upper lip droops, the presence
of vermilion inversion, the amount of bilateral commissure
movement, and the upper incisor show when smiling should
all be noted. Speech should be assessed. An intraoral exami­
nation should include evaluating dental hygiene and the evi­
dence of cheek biting.
The presence of synkinesis, the simultaneous contrac­
tion of two or more groups of muscles that normally do not
contract together, should be documented. The most com­
mon types of synkinesis are eye closure with smiling, brow
wrinkling when the mouth is moved, and mouth grimacing
when the eyes are closed.
The level of injury to the nerve, if it is unknown, can be
assessed clinically. Injury to the nerve within the bony canal
varies by patient. A thorough history and physical exami­
nation are imperative to avoid unfavorable results.
The patient’s emotional status, concerns, and expecta­
tions, must be determined. For some, attaining a symmet­
rical appearance at rest is more important than achieving
a true dynamic smile. Older patients are more likely than
younger patients to be worried about brow ptosis, ectro­
pion and drooping of the cheek with concomitant drooling,
deglutition, and impaired speech.
Patients who are unable to fully understand the pro­
posed reanimation plan and noncooperative patients are
more prone to poor results and dissatisfaction. This is sec­
ondarily related to poor compliance. It should be noted that
children will have a higher success rate to achieve sponta­
neous smiling because of their faster nerve fiber growth,
brain plasticity, and faster cortical “rewiring” in cases of
non–facial donor nerve reanimation.
The patient’s general health status must be evaluated;
its sustainability for free muscle transfer and reinnervation
must be carefully assessed.
This includes an assessment of the patient’s ability to
undergo a substantial operative procedure under general an­
esthesia and an evaluation of comorbidities that may affect
the fate of microvascular muscle transfer.
Errors in History Taking and in
Communicating with the Patient
In facial paralysis reconstruction, a complete symmetry and
normal function cannot be totally achieved. However, the
procedure can improve functional limitations such as lack
of corneal protection, speech problems, drooling, and facial
expression. When the effects of the paralysis are subtle, the
surgeon must assess the potential benefits to be obtained
from surgery, and this is often a function of how severe the
paralysis is perceived to be by the patient and an assess­
ment of the impact on the patient’s general well-being. At
the same time, it is crucial to address the patient’s expecta­
tions and determine whether they are realistic. The patient
should be counseled regarding the long time it would take
to achieve motion, which is usually around 5 to 12 months.
If reanimation is based on a non–facial nerve approach,
the patient should be well informed that he or she may
not achieve involuntary movement or a truly spontaneous
smile nor an identical smile to the contralateral side.
Reinnervation progresses slowly in older individuals.
However, it is difficult to determine what constitutes “older,”
because muscle reinnervation can occur at any age. We are
reluctant to perform cross-face nerve grafts on patients who
are older than 55 years.
Failure to determine the actual etiology of the injury or
the time of onset of paralysis may lead to a poor choice of

1049
Chapter 56 Facial Reanimation Surgery
The most devastating error at this stage is a functional
damage to the facial nerve on the normal side. Fortunately
this catastrophic complication is unlikely, because there are
typically two to four branches that activate the BZMC, and
the sacrifice of one of these branches does not generally
interfere with the final function of muscles in the ­normal
side. However, to avoid this possibility, the most dominant
branch, which creates the strongest contraction while stimu­
lated, should be used. For this a light amplitude of stimula­
tion should be used (nerve detector set to 0.5 mA), because
with stronger stimulation, the current can pass to other
branches through the surrounding tissue, stimulate them,
and create a stronger contracture than the specific branch
may create.
Careful examination of the patient’s smile pattern pre­
operatively, especially in congenital conditions, may reveal
that the acting group of smile muscles is limited in its action
or that only the zygomaticus major or minor is functioning.
In such cases, extra caution should be taken not to use the
single nerve branch to that muscle and rather to choose an­
other donor nerve or, with extreme caution, split the main
functioning nerve.
Facial nerve mapping clearly identifies which nerve fi­
bers stimulate the orbicularis oculi and the orbicularis oris or
lip retractors. When stimulated, the facial nerve branches that
produce a smile and no other movement are selected. If the
nerve that was chosen simultaneous to creating a smile also
activates the nostril or the eyelid, the future formed smile on
the paralyzed side will be activated by normal-side blinking
or by normal-side nostril motion. When this happens, eyelid
may result in loss of ipsilateral taste appreciation, hyperacu­
sis, and facial weakness, because the chorda tympani and
nerve to the stapedius may be injured at this level. Injury
to the seventh cranial nerve near the geniculate ganglion
will also result in decreased secretory function of the nose,
mouth, and lacrimal gland.
An assessment of other cranial nerves, particularly the
fifth if it may serve as a donor nerve, is also preformed both
to assess added morbidity to the facial paralysis and for pos­
sible donor motor nerves. Performing cranial nerve transfer
using the same nerve on the contralateral side with absent
or weak function may result in a devastating disability in
jaw motion if the masseter nerve was used or with tongue
function if the hypoglossal nerve was used.
Missing the presence of thick skin and fatty cheeks cre­
ates a higher risk for unsatisfactory outcome, because there is
a higher probability that muscle motion would go unnoticed
under the bulky soft tissue and skin (Fig. 56.3, Video 56.1).
Errors During Surgery
Facial Nerve–Based Reanimation for Long-
Lasting Paralysis
The first stage of the procedure involves dissection of the
facial nerve on the unaffected side through a preauricular
incision with a very short submandibular extension. When
preparing the nerves, the surgeon meticulously identifies
and individually stimulates nerve branches with a nerve
stimulator to map their action.
a
b
Fig. 56.3 (a) Before reconstruction. (b) After the reconstruction, the heavy face and cheeks make it hard to notice the underlying muscle
motion.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1050
When harvesting the gracilis muscle, special attention
should be taken to prevent an injury to the motor branch.
This can occur in some anatomical variations in which the
motor nerve that usually inserts into the muscle, together
with the vascular bundle, leaves the bundle for several mil­
limeters to 1 cm before arriving at the muscle belly. Such an
error may cause total failure of the procedure.
Another unfavorable result comes from a muscle harvest
that is too bulky, resulting in a cheek that is bulky and pro­
nounced facial asymmetry. To achieve an appropriately thin
cheek, the muscle is split longitudinally (about one third to
one fourth from its cut surface area), and the anterior por­
tion of the muscle is used. While dissecting that tiny strip
from the muscle, the surgeon must ensure the neurovascular
bundle enters into that segment and that a good contraction
can be created by the nerve stimulator.
To determine which segment of the muscle to harvest,
the surgeon should assess where the neurovascular bundle
enters the muscle, so when the muscle flap is set in place
the neurovascular bundle is not too far from the planned
nerve anastomosis.
Attaching the muscle to the modiolus–oral commis­
sure is a critical step of the procedure. It is usually sutured
using three to four 0–0 Vicryl sutures inserted into the fi­
brotic remnants of the paralyzed orbicularis oris muscle.
One suture connects to the commissure, two along the
upper lip, and one below the commissure. Preoperative
smile analysis determines the points of insertion. The sur­
geon must be careful not to position the perioral sutures
too superficially, a condition that will lead to unaesthetic
indentations on the skin and lip eversion with every mus­
cle contraction and with smiling. Correct insertion of the
muscle also allows a noticeable nasolabial crease. Failure
creates facial asymmetry with no nasolabial fold (Fig. 56.6,
Video 56.4).
closure or unsightly motion shows on the normal side when
trying to create a smile (Fig. 56.4, Video 56.2).
Also, if the branch that is chosen is too small and carries
a small number of functioning axons, an unnoticeable weak
contraction and a poor smile will show on the paralyzed
side. The sural nerve is the usual donor nerve. It is harvested
with the use of a nerve stripper. Stripping of the nerve does
not appear to affect its function as a graft.9
The proximal ends of the donor facial nerve branches
are sutured to the distal end of the nerve graft such that
regenerating axons will travel in a distal-to-proximal direc­
tion down the graft to prevent them from diverging into side
branches and not reaching their target. The current prac­
tice is to use a short nerve graft, approximately 12 cm in
length, and to bank the free end in the upper buccal sulcus.
A shorter nerve graft achieves stronger muscle contraction
and at a shorter time (around 6 months). Placing a longer
nerve graft may delay the time for a second stage procedure,
and its potential “power” may be decreased.
In the second stage the gracilis muscle flap is harvested
and transferred to the affected side.
For incomplete facial paralysis, during that stage the in­
set of the muscle on the affected side may lead to an injury
to the nerve branches responsible for the residual motion
and possibly lead to a worse state of paralysis.
Another possible error when dissecting the cheek and
preparing the recipient side is subcutaneous dissection of
the cheek flap that is too superficial, which may later lead
to adhesions between the skin and the transferred muscle
(Fig. 56.5, Video 56.3).
When preparing the recipient blood vessels, a dis­
section that is too short may result in a need to place the
transferred muscle in a less-favorable orientation. Thus a
deficient transverse motion may be created rather than an
oblique smile.
a
b
Fig. 56.4 Before (a) and after (b) an unintentional use of a nerve branch that activated the nostril to create a smile.

1051
Chapter 56 Facial Reanimation Surgery
a
b
c
d
Fig. 56.5 A subcutaneous dissection of the cheek that is too superficial may create adhesions between the dermis and the muscle. (a) Pre­
operatively. (b) Postoperatively. (c) Skin adhesion to the muscle evident on the lateral postoperative view. (d) After fat injection under the
skin adhesion and contracted area.
a
b
Fig. 56.6 Before (a) and after (b) a failure to reproduce the nasolabial fold crease.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1052
the commissure and observing a slight motion that creates
teeth show (Video 56.5).
A very common untoward phenomenon is an inabil­
ity to properly elevate the upper lip and to create teeth
show. This is related to the necessity of placing a function­
ing muscle in a vertical orientation to the lip rather than
an oblique one to move the oral commissure. However, the
vertical distance is so short (up to the orbital rim) that such
a short muscle will not create a proper excursion (Fig. 56.7,
Video 56.6).
For older patients with long-standing paralysis, the long
oral orifice must be shortened by a macrostomia technique;
failure to do so may lead to an unaesthetic even ­longer
The preoperative smile analysis and finding the vector
of smile motion is crucial for determining where to place
the origin of the muscle. The muscle may be attached to the
zygomatic body, arch, temporal fascia, or preauricular fascia
in different angles in relation to the commissure.
To create a significant motion, a precise tension for the
muscle inset should be determined. This is because excur­
sion is determined by the relative overlap between the mus­
cle myofibrils and therefore their relative motion along each
other.
An overly loose muscle fixation will lead to poor tone
and a weak smile. The appropriate muscle tension is deter­
mined when pulling on the muscle that is already fixed to
a
b
Fig. 56.7 (a) Preoperatively. (b) Postoperatively the patient is unable to elevate the upper lip and has failure of upper lip muscle–lip fixation.
a
b
Fig. 56.8 Failure to shorten the long oral orifice in an older patient with a long-standing condition. (a) Preoperatively. (b) A gracilis muscle
that was too bulky and had stimulation that was too strong was used because of nonselective harvest of the masseter motor nerve.

1053
Chapter 56 Facial Reanimation Surgery
a
b
Fig. 56.9 Inability to spontaneously operate the muscle and smile. The patient has desynchronization of motion between both sides.
a
b
Fig. 56.10 (a) An overly large recipient masseter motor nerve. (b) After a revision procedure to disconnect and weaken part of the nerve.
commissure that is pulled up by the functioning muscle in
an unpleasing fashion.
Muscle motion does not usually occur before 6 to 10
months, and maximal movement is usually gained by 18
months. At this stage, resting tension and symmetry at rest
in addition to muscle excursion at smile are assessed. Al­
though rare, some patients require a third procedure for re­
vision to adjust the muscle tension, direction, or bulk.
Non–Facial Donor Nerve Reanimation
The motor nerve to the masseter courses downward and
anteriorly from the superoposterior border of the masseter
in an oblique direction. The nerve is usually located on the
undersurface of the masseter muscle and enters the muscle
belly approximately 2 cm below the zygomatic arch. Proper
careful dissection of the nerve has a considerable learning
curve. The nerve courses through the muscle, giving off a
variety of branches. Thus the nerve can be traced distally,
divided, and reflected proximally and superiorly to move to
a position suitable for neural anastomosis.
In the muscle transfer procedure, the recipient masse­
ter motor nerve stump must not be too large (this is typical
at the proximal part of the nerve). Because reinnervation
by the masseter nerve is much stronger than that accom­
plished by the contralateral facial nerve, it may reach the
same or stronger level of movement as the unaffected side
(Fig. 56.8, Video 56.7). The use of the masseter motor nerve
branch may change with time and practice to allow a spon­
taneous smile, but in many cases spontaneity of the smile
and symmetrical action is lacking (Figs. 56.9 and 56.10, ­
Videos 56.8 and 56.9).

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1054
side is performed for the purpose of dynamic reconstruction,
a miraculous unplanned revival of the injured facial nerve
and muscles is noted with spontaneous motion together
with the reconstructed smile (Fig. 56.12, Video 56.11).
In some patients the paralyzed-side dissection initiates
unplanned spontaneous innervation of the transplanted
gracilis muscle by the masseter nerve, although the opera­
tive plan and its execution used the contralateral facial nerve
as a muscle innervator (Fig. 56.13, Video 56.12).
Avoiding Postoperative Complications
Potential complications in facial paralysis reconstruction
are fortunately not common. Early complications are simi­
lar to those for any microsurgical procedure:
•• Bleeding
•• Infection
•• Thrombosis
•• Vascular compromise to the muscle flap
Late complications or unfavorable results are more com­
mon and complex to deal with. They include (1) incorrect
muscle positioning and (2) excess bulk. Incorrect muscle
positioning relates to the insertion at the oral commissure
and upper lip, which must be accurate and permanent,
as previously outlined. The origin needs to be accurately
placed under the proper tension to allow the appropriate
muscle excursion, spread out to reduce bulk, and lead to the
correct smiling vector. As for excess bulk, great care needs
to be taken to reduce bulk at the side of muscle placement.
This involves the use of only a small strip of muscle (5–15 g
in a child of approximately 5 years of age and up to 15–25 g
in an adult). Removal of the buccal fat pad may also aid in
decreasing the likelihood of excess bulk. Most prevalent is
the inability to constantly re-create the exact excursion as
Bilateral Facial Paralysis
Reconstruction
In bilateral facial paralysis, such as in Möbius syndrome,
the use of the motor nerve to the masseter is an excellent
solution, because the masseter muscles are normal in these
patients. It has proved to be extremely effective in help­
ing lower lip incompetence and drooling as well as speech
­difficulties, especially those requiring bilabial sound pro­
duction. Most importantly, however, it is effective in pro­
viding patients with an acceptable level of smile animation
that is not possible with other techniques.10,11 Each side
is operated separately, spaced about 2 months apart, and
symmetry is expected between the two sides. This is not
­totally predictable, however, and asymmetry may still re­
sult (Fig. 56.11, Video 56.10).
General Considerations
Unnoticed or Untreated Normal Lower Lip
Depressor Deformity
It is common to have remnant ipsilateral functioning lower
lip depressors, especially with congenital conditions, and in
many patients with total facial paralysis the normal contra­
lateral lower lip depressors have an unsightly exaggerated
down and oblique pull. These two dynamic deformities
should not be overlooked, because they increase the un­
pleasant sight of the paralyzed-face smile. Optional correc­
tions involve either Botox injection or myomectomy to that
group of muscles.
Beneficial Errors
We have also noted rare cases with beneficial errors. In pa­
tients in whom subcutaneous dissection of the paralyzed
a
b
Fig. 56.11 (a) Bilateral residual risorius muscle action. (b) Inability to create total symmetry in bilateral facial paralysis.

1055
Chapter 56 Facial Reanimation Surgery
muscular pedicle at risk. If the vector is incorrect, it can be
repositioned relatively easily, though with significant risk
to the pedicle.13
Because the neurovascular pedicle enters the muscle
belly from the undersurface, excess bulk can be addressed
by tangentially shaving the superficial surface of the muscle.
To facilitate this it is helpful to position the motor nerve on
the deep surface of the muscle at the time of muscle trans­
plantation.
When the problem is a poor excursion, there are few
options. It may help to tighten the muscle if it has been in­
serted too loosely, but care must be taken not to over-pull
the mouth angle.
the normal side; thus muscle excursion may not meet the
expectations of the surgeon or the patient and may lead to
a relative disappointment on both sides.12
Muscle detachment at the insertion side is the most dif­
ficult to correct. Open surgical reinsertion can be performed.
Upon dissection to the commissure, the nerve or vascular
bundle may be injured and may leave the commissure too
tight and the mouth distorted. This can be avoided by using
a tendon graft to connect the displaced muscle to the oral
commissure and upper lip.
If the muscle is too tight it can be released at its origin
and “slid” toward the mouth. However, this may require a
radical dissection of the muscle and again puts the neuro­
Fig. 56.12 A patient in whom the dissection created unplanned revival of the injured facial nerve, 6 years after his Bell’s palsy. The right
paralyzed side has independent motion, although it was supposed to be innervated by the cross-face nerve graft that was attached to the
muscle. Also note the nontreated normal-side lower lip depressors when smiling with an open mouth.
Fig. 56.13 Patient in whom the second-stage face dissection created unplanned innervation of the gracilis muscle by the masseter nerve
(the muscle was actually connected to a cross-face nerve graft).

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1056
neural repair is best, if possible. Reinnervation of the BZMC
should not be attempted beyond 10 months of paralysis with­
out muscle transfer. Reinnervation based on the facial nerve
should be the goal, even at the cost of conducting a cross-face
procedure or a two-stage cross-face nerve graft and gracilis
muscle transfer, a validated, reliable procedure that plays a
pivotal role in dynamic reanimation for facial paralysis.
The innervation, placement, anchorage, direction, and
amplitude of motion of the muscle transplant are critical to
success. Staged adjustments have been suggested, but asym­
metry continues to be a challenge.
Fundamental to progress in any field is a reliable, univer­
sally acceptable, and simple assessment. In facial paralysis,
it is necessary to measure muscle excursion, direction of
movement, volume symmetries, and contour irregularities
to assess the level of the results of repair and reconstruc­
tion. To compare the results, a common tool is needed. A
reliable common instrument of evaluation is also needed
to assess results from a psychosocial standpoint. Progress
has been made on physical measurement and psychosocial
profile tools, and there is hope that these will be universally
accepted and applied in the future.
If this is impossible and further surgery is requested,
a thorough discussion with the patient should take place,
emphasizing that improvement will be difficult and risky
to the already moderate results. The surgeon must explore
the buccal sulcus anastomosis between the cable nerve graft
and the motor branch to the muscle and redo the anasto­
mosis if neuroma or scarring are found. If that anastomosis
looks normal, the muscle transfer stage may need to be re­
done with a second muscle. If the cause of the failure is not
clear, it may be wise to use another motor nerve to power
the new muscle. For example, the gracilis motor nerve may
be detached from the cross-face graft and transferred to con­
nect to the masseter motor nerve.
Conclusion
Facial nerve paralysis presents with a very high success
rate. Most operated patients who achieve a near-normal
or even weak smile results are relatively satisfied with any
motion in their paralyzed faces.14
Nevertheless, to overcome unfavorable results, several
fundamental principles should be considered: Immediate
9. Koller R, Frey M, Rab M, et al. Histological examination of
graft donor nerves harvested by the stripping technique.
Eur J Plast Surg 1995;18:24
10. Zuker RM, Goldberg CS, Manktelow RT. Facial anima­
tion in children with Möbius syndrome after seg­
mental gracilis muscle transplant. Plast Reconstr Surg
2000;106(1):1–8, discussion 9
11. Terzis JK, Noah EM. Dynamic restoration in Möbius and Mö­
bius-like patients. Plast Reconstr Surg 2003;111(1):40–55
12. Bae YC, Zuker RM, Manktelow RT, Wade S. A comparison
of commissure excursion following gracilis muscle trans­
plantation for facial paralysis using a cross-face nerve
graft versus the motor nerve to the masseter nerve. Plast
Reconstr Surg 2006;117(7):2407–2413
13. Takushima A, Harii K, Asato H, Momosawa A. Revisional
operations improve results of neurovascular free muscle
transfer for treatment of facial paralysis. Plast Reconstr
Surg 2005;116(2):371–380
14. Terzis JK, Olivares FS. Long-term outcomes of free-mus­
cle transfer for smile restoration in adults. Plast Reconstr
Surg 2009;123(3):877–888
References
1. Aviv JE, Urken ML. Management of the paralyzed face
with microneurovascular free muscle transfer. Arch Oto­
laryngol Head Neck Surg 1992;118(9):909–912
2. Manktelow RT, Tomat LR, Zuker RM, Chang M. Smile re­
construction in adults with free muscle transfer innervat­
ed by the masseter motor nerve: effectiveness and cere­
bral adaptation. Plast Reconstr Surg 2006;118(4):885–899
3. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle
transplantation for facial paralysis. Plast Reconstr Surg
1997;99(7):1905–1921
4. Tate JR, Tollefson TT. Advances in facial reanimation. Curr
Opin Otolaryngol Head Neck Surg 2006;14(4):242–248
5. Braam MJ, Nicolai JP. Axonal regeneration rate through
cross-face nerve grafts. Microsurgery 1993;14(9):589–591
6. Yoleri L, Songür E, Mavioğlu H, Yoleri O. Cross-facial
nerve grafting as an adjunct to hypoglossal-facial nerve
crossover in reanimation of early facial paralysis: clini­
cal and electrophysiological evaluation. Ann Plast Surg
2001;46(3):301–307
7. Manktelow RT. Microvascular Reconstruction: ­Anatomy,
Applications, and Surgical Technique. New York, NY:
Springer-Verlag; 1986
8. Gillies H. Experiences with fascia lata grafts in the op­
erative treatment of facial paralysis. Proc R Soc Med
1934;27(10):1372–1382

1057
Chapter 56 Facial Reanimation Surgery
Discussion by Ronald M. Zuker
Facial paralysis is a complex condition. This discus­
sion emphasizes the key points in facial paralysis re­
construction and particularly explores the technical
aspects of success and avoiding an unfavorable result.1
Chapter 56 outlines whether a nerve-based re­
construction is possible and, if not possible, whether a
muscle-based reconstruction will provide the desired
results. Dr. Gur has championed the use of the ipsilateral
facial nerve in incomplete paralysis as a motor for a seg­
mental gracilis muscle transplant. The results have been
outstanding (personal communication, 2016).
The importance of discussing and understanding
the patient’s expectations cannot be overemphasized.
This understanding is the only way for the surgeon to
determine the correct procedure for that particular pa­
tient and produce a favorable outcome from the sur­
geon’s perspective and, most important, from the pa­
tient’s perspective.
My approach to the reconstruction of the midface
in a patient with facial paralysis is basically the same as
outlined in the chapter. In young patients with minimal
asymmetry at rest, adequate excursion can be achieved
with a cross-face nerve graft, followed about 9 months
later by a segmental gracilis muscle transplant. On the
other hand, for an older patient with excessive droop
at rest and a very asymmetrical smile, it is difficult to
achieve symmetry and adequate excursion for smile
with the input from a cross-face nerve graft. In these
situations, I prefer to power the segmental gracilis mus­
cle transplant with the motor nerve to the masseter.
For the cross-face nerve graft procedure, I prefer to
use a variable-intensity nerve stimulator to accurately
map out the facial nerve branches. I explore the nor­
mal side to create a facial nerve map and select the best
nerve. A powerful input is critical to success, so I use a
powerful nerve branch, usually the largest, that stim­
ulates the zygomaticus major and minor muscles, as
well as the levator (Fig. 56D.1). An alternative powerful
branch that stimulates the same musculature is always
left untouched so as to not weaken the normal side.
This powerful input is then transferred to the para­
lyzed side by a sural nerve graft. I use the proximal part
of the sural nerve from the popliteal fossa to the midcalf
to concentrate the axons and again get as much input as
possible2 (Fig. 56D.2). I am currently working on other
technical maneuvers to increase the input from the
cross-face nerve graft into the muscle. One of these in­
volves electrical stimulation of the selected ­facial nerve
branch on the normal side. My group anticipates accel­
erated axon outgrowth, as has been demonstrated in
both the laboratory3,4 and in clinical trials.5,6 I also carry
out a coaptation of the distal end of the sural nerve graft
to a fascicle of the infraorbital nerve on the paralyzed
side, trying to maintain the integrity of the Schwann
cells (Fig. 56D.3). In the laboratory, the distal stump of a
nerve graft can be protected from Schwann cell atrophy
by coaptation to an adjacent nerve.7,8 All of these mea­
sures are designed to increase input of the facial nerve
stimulus to the muscle transplant, and thus increase ex­
cursion. One of the unfavorable results that was noted
previously is inadequate muscle excursion after trans­
plantation where the muscle segment is powered by
a cross-face nerve graft.9 The main advantage of the
cross-face nerve graft is that the activity is spontane­
ous. However, the disadvantage is that the excursion
is less than normal. By using a large branch of the fa­
cial nerve, a short sural nerve graft from the upper calf
portion of the nerve, intraoperative stimulation of the
selected facial nerve branch, and distal coaptation of
the sural nerve, I hope to provide adequate excursion
Fig. 56D.1 Stimulation of the facial nerve branch with a nerve
stimulator. A large, powerful branch that innervates the appro­
priate facial muscles is selected. A second similar branch is left
so as not to weaken the normal side.
Fig. 56D.2 Procurement of a sural nerve graft from the popliteal
fossa proximally to the midcalf distally. A nerve stripper is used
from proximal to distal.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1058
to the muscle transplant that will occur spontaneously,
as it is powered by the facial nerve on the normal side
(Fig. 56D.4).
In congenital facial paralysis reconstruction, it is dif­
ficult to achieve exact symmetry of the nasolabial crease
to the normal side. There is no residual facial muscula­
ture into which to insert the muscle transplant.
In the second stage of the reconstruction, a seg­
ment of the gracilis muscle is transplanted to the face.
Our technique is exactly as described in the chapter. It
is important to avoid injury to whatever facial nerve
branches remain functional on the weak side. It is also
critical to avoid having the transplanted muscle adja­
cent to the dermis as a result of a superficial dissection
or excessive removal of subcutaneous fat in an effort
to avoid excess bulk. This will cause dimpling and dis­
tortion with muscle activation, which is very difficult,
if not impossible, to fully correct. The surgeon should
not compromise on muscle positioning and orienta­
tion as a result of the location of the vessels and the
nerve. Finally, it is critical to avoid injury to the neuro­
vascular bundle when elevating the segmental gracilis
muscle flap.
Success in Facial Reanimation
There are four key technical points to ensure success in
muscle transplantation to the face for facial reanimation.10
Accurate Muscle Positioning
The first is accurate muscle positioning. Preoperatively,
the vector and site of insertion on the normal side are
noted. I try to replicate this on the paralyzed side with
the muscle transplantation. Through a preauricular in­
cision with a small submental extension, the oral com­
missure and the upper lip can be identified and sutures
placed in an accurate position. This is perhaps the most
difficult and the most crucial part of the entire opera­
tion. I use no. 1 Vicryl sutures and try to replicate the
normal commissure movement. This is done intraopera­
tively by applying traction on these sutures (Fig. 56D.5).
In addition to getting these sutures in the proper loca­
tion, they must be secured to the muscle so they will not
pull through. A series of mattress sutures is placed along
the edge of the muscle and the anchoring sutures are
placed proximal to these so they will not pull through
the longitudinal muscle fibers (Fig. 56D.6).
a
b
c
Fig. 56D.3 (a) Electrical stimulation being carried out on the selected branch of the facial nerve. The technical team is adjusting
the delivery machine to 20 Hertz. (b) Bipolar electrodes on either side of the selected facial nerve branch. (c) The intraoral coap­
tation of the sural nerve to a small branch of the infraorbital nerve on the paralyzed side.

1059
Chapter 56 Facial Reanimation Surgery
a
b
c
d
Fig. 56D.4 Unilateral congenital facial paralysis treated with a cross-face nerve graft and 1 year later by segmental gracilis muscle
transplantation. (a) Preoperatively at rest. (b) Preoperatively with smile. (c) Postoperatively at rest. (d) Postoperatively with smile.
Fig. 56D.5 Intraoperative photo showing anticipated smile with
traction on the anchoring suture.
Fig. 56D.6 A row of mattress sutures is placed along the end
of the muscle that will be placed in the pocket and secured to
the oral commissure and upper lip. These sutures will hold the
anchoring sutures, shown being inserted proximal to the row of
mattress sutures. This prevents these anchoring sutures from
pulling through the longitudinal fibers of the muscle.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1060
Reduction of Bulk on the Reconstructed
Side
The second key to success is reduction of bulk on the
reconstructed side. It is important not to use too much
muscle; I generally use about one third of the circum­
ference of the gracilis muscle (Fig. 56D.7). I also remove
the buccal fat pad, which lies in almost the exact same
location that the new muscle transplant will lay. In this
way, I try to reduce the likelihood of excess bulk over
the location of the transplanted muscle. I also remove
a small amount of the deep subcutaneous fat, again to
reduce bulk. However, I do not remove the superficial
fat for fear of having the muscle become adherent to
the dermis.
Creation of Strong Motor Input
The third key to success is the creation of a strong mo­
tor input. For unilateral facial paralysis, my colleagues
and I have described the measures taken to increase
the power of our cross-face nerve graft. In situations in
which I cannot use a cross-face nerve graft, I prefer the
motor nerve to the masseter, which has a very power­
ful input and can in fact lead to normal commissure ex­
cursion. Our indications for the use of the motor nerve
to the masseter include situations in which cross-face
nerve grafting is not possible, such as bilateral facial
paralysis. This is most commonly seen in Möbius syn­
drome, which involves the sixth and seventh cranial
nerves and has a number of other associated condi­
tions. Bilateral seventh nerve paralysis can also be seen
after intracranial tumor excisions. I also use the motor
nerve to the masseter if the cross-face nerve graft may
not produce effective or adequate commissure excur­
sion. This is seen in older patients or when there is a
very powerful smile on the normal side. I generally use
the motor nerve to the masseter after a failed previ­
ous cross-face nerve graft muscle transplant procedure.
It would be difficult to explore the normal side again,
because it would be quite scarred. It would also be
quite risky to select another branch of the facial nerve
on the normal side, because the normal side could be
significantly weakened. Finally, I use the motor nerve
to the masseter when only a single-stage procedure is
requested or is possible.
The motor nerve to the masseter can be found using
Borschel’s rule.11 It is located 3 cm anterior to the tragus
on a line parallel to the zygomatic arch and 1 cm inferior.
It is found deep in the musculature between the middle
and lower lobes and courses downward and anteriorly
toward the oral commissure. It can be identified using
the nerve stimulator as a small white structure cours­
ing in the aforementioned direction that produces jaw
movement when stimulated (Fig. 56D.8). Thus a strong
motor input is essential and can be provided with a ro­
bust cross-face nerve graft or the use of the motor nerve
to the masseter.
Appropriate Muscle Tension
The fourth key to success is placing the muscle under ap­
propriate tension. It should just barely move the corner
of the mouth and be secured to the temporal fascia with
heavy mattress sutures. The length of the transplanted
muscle is critical. The required length is measured out
at the time of muscle procurement and will extend from
the oral commissure to the root of the helix. This creates
a longer muscle length than the length of the zygomati­
cus major or minor. This is helpful in that muscle excur­
sion is a reflection of muscle fiber length. The longer the
muscle, the greater the excursion. Placing the origin in
Fig. 56.7 Procurement of gracilis muscle from the thigh for
transplantation to the face. Only about one third of the circum­
ference of the muscle is used. The length needed is determined
by measuring the distance from the oral commissure to the root
of the helix and adding 1 cm at each end to account for the su­
tures needed to secure the muscle.
Fig. 56D.8 The motor nerve to the masseter is noted in the
depths of the masseter muscle coursing obliquely downward
from below the zygomatic arch to the oral commissure. Using
Borschel’s rule, it can be found 3 cm anterior to the tragus and
1 cm below the zygomatic arch.

1061
Chapter 56 Facial Reanimation Surgery
the temporal fascia creates a longer muscle, and thus
longer muscle fiber length and increased excursion. So
the muscle should be placed under just enough tension
to move the oral commissure. If it is too loose the excur­
sion is not maximized. If it is too tight, it will distort the
oral commissure (Fig. 56D.9).
Complications are not common. By focusing on
the approach described and paying attention to the
four keys to success, most can be avoided. One of the
most difficult aspects is achieving symmetry in bilateral
muscle transplant reconstructions (Fig. 56D.10). Sur­
geons must do their best to try to get as symmetrical
Fig. 56D.9 (a) The muscle transplant is secured under the correct tension so that the oral commissure has a very slight pull and is
even with the normal side. If it is too loose, contraction will not lead to sufficient excursion. If it is too tight, the commissure will
be distorted. The muscle is in position from the oral commissure to the temporal fascia. A drain is in place. (b) After cheek flap
closure. A slight pull is evident at the commissure.
a
b
a
b
c
d
Fig. 56D.10 Bilateral facial paralysis
­(Möbius syndrome) treated with staged
segmental gracilis muscle transplantation
innervated by the motor nerve to the mas­
seter. (a) Preoperatively at rest. (b) Postop­
eratively 15 years later, at rest. Key features
are extent of bulk bilaterally and the rest
position of the oral commissures. (c) Post­
operatively with a small smile. Key features
are the location of pull at the commissure,
the vector of pull, the extent of excursion,
and symmetry of the created smile.
(d) Postoperatively with full smile.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1062
movement and crease formation as possible, though it
is never exact. The avoidance of unfavorable muscle po­
sition, excess bulk, a weak or ineffective motor nerve,
and unprecise tension are all critically important. Re­
covery from these unfavorable results is not easy and
often is impossible. Thus it is imperative to get it right
the first time.
References
1. Fattah A, Borschel GH, Manktelow RT, Bezuhly M,
Zuker RM. Facial palsy and reconstruction. Plast Re­
constr Surg 2012;129(2):340e–352e
2. Manktelow R, Zuker R. Cross-facial nerve graft—the
long and short graft: The first stage for microneuro­
vascular muscle transfer. Oper Tech Plastic Reconstr
Surg. 1999;6:174–179
3. Al-Majed AA, Neumann CM, Brushart TM, Gordon T.
Brief electrical stimulation promotes the speed and
accuracy of motor axonal regeneration. J Neurosci
2000;20(7):2602–2608
4. Brushart TM, Hoffman PN, Royall RM, Murinson
BB, Witzel C, Gordon T. Electrical stimulation pro­
motes motoneuron regeneration without increas­
ing its speed or conditioning the neuron. J Neurosci
2002;22(15):6631–6638
5. Wong JN, Olson JL, Morhart MJ, Chan KM. Electri­
cal stimulation enhances sensory recovery: a ran­
domized controlled trial. Ann Neurol 2015;77(6):
996–1006
6. Gordon T, Amirjani N, Edwards DC, Chan KM. Brief
post-surgical electrical stimulation accelerates axon
regeneration and muscle reinnervation without af­
fecting the functional measures in carpal tunnel syn­
drome patients. Exp Neurol 2010;223(1):192–202
7. Sulaiman OA, Gordon T. Role of chronic Schwann cell
denervation in poor functional recovery after nerve
injuries and experimental strategies to combat it.
Neurosurgery 2009; 65(4 Suppl): A105–A114
8. Höke A, Gordon T, Zochodne DW, Sulaiman OA. A
decline in glial cell-line-derived neurotrophic factor
expression is associated with impaired regeneration
after long-term Schwann cell denervation. Exp Neu­
rol 2002;173(1):77–85
9. Bae YC, Zuker RM, Manktelow RT, Wade S. A com­
parison of commissure excursion following graci­
lis muscle transplantation for facial paralysis us­
ing a cross-face nerve graft versus the motor
nerve to the masseter nerve. Plast Reconstr Surg
2006;117(7):2407–2413
10. Zuker RM. Facial paralysis and the role of free
muscle transplantation. Ann Chir Plast Esthet
2015;60(5):420–429
11. Borschel GH, Kawamura DH, Kasukurthi R, Hunter
DA, Zuker RM, Woo AS. The motor nerve to the mas­
seter muscle: an anatomic and histomorphometric
study to facilitate its use in facial reanimation. J Plast
Reconstr Aesthet Surg 2012;65(3):363–366

1063
Reconstruction of the Chest
and Abdomen
Mark W. Clemens and Charles E. Butler
Reconstruction of the chest wall and abdomen covers a vast
array of surgical procedures, all intentioned to preserve
and restore the critical dynamic function of these unique
anatomic regions. Proper patient selection and meticulous
surgical technique may help to mitigate complications but
can never completely eliminate unfavorable outcomes.
Therefore the ability for early recognition and the knowl­
edge of corrective interventions of common adverse events
are fundamental to the reconstructive surgeon’s armamen­
tarium. Restoration of chest and abdominal wall integrity
is a slow process that requires recuperation and fascial and
sometimes rigid support through a critical remodeling pe­
riod; this is affected by mechanical strain, genetic predis­
position in collagen formation, and predisposing risk fac­
tors such as tobacco use, diabetes, nutritional status, and
obesity. This chapter focuses on complications and their
management in chest and abdominal wall reconstruction
with a focus on patient diagnosis, surgical techniques, and
adverse events inherent to reconstructive procedures.
Avoiding Unfavorable Results
and Complications in Chest and
Abdominal Reconstruction
The chest and abdomen are unique anatomical units with
very specific surgical complications and adverse events.
The chest wall functions as a protective cage around the
vital organs of the body, and significant disruption of its
structure can have dire respiratory and circulatory conse­
quences.1 The complex interplay of twelve paired ribs with
the internal and external muscles that compose the chest
wall has both a structural and a functional role. The chest
wall protects the heart, lungs, and liver; provides a flexible
skeletal framework to stabilize the actions of the shoulder
and arm; and promotes respiratory movement, all while re­
liably delivering more than 20,000 breaths a day. Chest wall
complications are associated with significant morbidity
and rapid life-threatening consequences. The management
and reconstruction of complex chest wall defects has sig­
nificantly improved over the past half century, with long-
term success rates changing from 50% to the current 90 to
99% and hospital stays reduced from an average of 84 days
to less than 13 days.2 The past several decades have seen a
marked improvement in the management and reconstruc­
tion of complex chest wall defects.3 Widespread acceptance
of muscle and myocutaneous flaps such as the latissimus
dorsi, pectoralis major, serratus anterior, and rectus ab­
dominis has led to a sharp decrease in infections and mor­
CHAPTER
57
Summary Box
Adverse Events After Surgical Intervention
of the Chest and Abdominal Wall
Common Complications
•• Infection
•• Seroma
Chest Wall
•• Flail chest/paradoxical motion
•• Empyema
•• Mediastinitis
•• Bronchopleural fistula
Abdominal Wall
•• Hernia
•• Enterotomy
•• Abdominal bulge
•• Enterocutaneous fistula

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1064
lies, and trauma. Each indication has an underlying distinct
pathophysiology, which must be specifically addressed for
successful surgical correction and to avoid iatrogenic com­
plications. Hernias of the abdominal wall can result from
genetically impaired collagen formation, deposition, orga­
nization, or degradation; from wound-healing deficiencies;
and from injury, failed laparotomy closures, or failed hernia
repairs.7 Decades ago, it was suggested that both primary
and recurrent hernias resulted from abnormal collagen me­
tabolism.8 Original proposed risk factors for the develop­
ment of hernias included tobacco use and a strong family
history of hernia, which suggests a genetic predisposition.
Subsequently, ratios of type I and type III collagen and tissue
metalloprotease expression in patients with inguinal and
incisional hernias were studied to try to isolate a cause.9
Further studies have suggested that mechanical strain on
load-bearing tissues can induce secondary changes in tis­
sue fibroblast function that in turn can result in failure of
abdominal wall repairs.10
Preoperative Planning and Patient
Selection
A physical examination should be performed to assess the
patient’s general condition, the abdominal wall integrity,
the extent and location of any abdominal wall abnormali­
ties, and the presence of scars that could become an obsta­
cle to raising reliable tissue flaps. Routine laboratory tests
and a nutritional workup are advised. Preoperative com­
puted tomography to examine the defect characteristics
and abdominal wall anatomy and vascularity is helpful for
surgical planning. Correct diagnosis of chest and abdominal
wall defects is critical to proper management. After an ap­
propriate clinical evaluation, imaging studies are a helpful
adjunct for detection and diagnosis of chest and abdomi­
nal defects and defining the relevant wall anatomy. Differ­
ent imaging modalities are available to evaluate defects.11
Computed tomography (CT) allows for visualization of the
thoracic cage, intra-abdominal organs, and the abdomi­
nal wall; three-dimensional data sets; and multiplanar
reformation capabilities. CT may assist in detecting lung
collapse, fluid collections, bowel obstruction, incarcera­
tion, strangulation, and traumatic wall hernias. Magnetic
resonance imaging (MRI) also permits the detection of
soft tissue defects and abdominal wall hernias, although
this modality does not usually offer further sensitivity and
therefore may be cost prohibitive.
In the repair of chest and abdominal wall defects, the
surgeon must consider a multitude of factors to identify
the appropriate surgical technique to accomplish the re­
constructive goals. An individualized approach is required
and must take into account the patient’s age, comorbidities,
physiological status, defect size, available local tissue, and
presence of contamination. In addition, the patient’s pulmo­
nary function should be evaluated preoperatively (e.g., with
spirometry) because most patients undergoing major chest
tality.4 Successful reconstructions are critically dependent
upon a detailed knowledge of the functional anatomy and
blood supply of the chest and the underlying pathophysiol­
ogy of a particular disease process.
Abdominal wall reconstruction patients have varied
presentations, and postoperative complications have nu­
merous causes. The goals of abdominal wall reconstruction
are to reestablish the integrity of the myofascial layer and
provide external cutaneous coverage. In the United States,
there are an estimated 4 million laparotomies performed
annually, associated with a 2 to 30% incidence of incisional
hernia, which produces roughly 150,000 to 250,000 ventral
hernias.5 This equates to a cost of approximately $2 billion
at a time when health care is transitioning toward value-
based reimbursement and pay for performance concepts,
and when efficiency and cost containment are prioritized
with little tolerance for complications.6 Surgical complica­
tions can result any time but are particularly common after
tumor resection, necrotizing soft tissue infections, or trau­
matic injury. These clinical scenarios represent the most
complicated abdominal wall reconstructions, sometimes
requiring multiple staged procedures.
Physiology, Basic Science, and the
Disease Process
The inspiratory and expiratory muscles of the rib cage work
in a precisely coordinated movement to execute a func­
tional breath. In the pleural cavity, the lung remains in an
inflated state by mechanical coupling of the chest wall and
the lung. The work of breathing is minimized by mesothe­
lial cells with microvilli that are enmeshed in hyaluronic
acid–rich lubricants. Elevated movement of the ribs leads
to forced inspiration by increasing the dimensions of the
chest through a “bucket-handle” motion and by elevation
of the sternum through a “pump-handle” motion. The
muscles of inspiration work actively to create a reduced
intrapleural pressure to induce inhalation. Because of its
distinctive curved geometry and specialized metabolic
demands, the diaphragm is the most important respira­
tory muscle. With assistance from the external intercostal
muscles, the diaphragm contracts during inspiration to en­
large the thoracic cavity. Paired sternocleidomastoids and
scalene muscles act as secondary accessory muscles to aid
in raising the sternum and elevating the upper ribs. Upon
relaxation of the diaphragm, the elastic recoil of the lung
in addition to contraction of the abdominal muscles leads
to passive expiration. Pulmonary function tests measure
forced expiratory volume in 1 second (FEV1), tidal volume,
and the ratio of FEV1 to forced vital capacity ratio to quan­
tify this process. The pathophysiology of lung disease may
be broadly classified into either obstructive or restrictive
disease. Obstructive processes involve the impediment of
expiration by obstruction of the bronchioles and bronchi.
Indications for abdominal wall reconstruction are mul­
tifactorial and include tumor ablation, congenital anoma­