Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

BRACHIAL PLEXUS • 683
FIGURE 57-10. An 18-year-old man sustained right brachial plexus palsy secondary
to a motor vehicle accident. Preoperative evaluation revealed an upper plexus injury (loss
of shoulder abduction, external rotation, and elbow fl exion) (A). Six months after the injury,
an exploration of the right brachial plexus revealed C5 and C6 root avulsions. Plexus
reconstruction was performed with interposition sural nerve grafts as follows: C3 and
C4 motor roots to the axillary nerve (AX); and contralateral lateral pectoral (LP) to the
musculocutaneous nerve (MC). End-to-end coaptation of the distal accessory (Acc) to
the suprascapular (SS) nerve was also performed (B). Three years postoperatively, he
demonstrates excellent shoulder abduction (C) and full elbow fl exion (D). (Part A, B: From
Terzis JK, Kostopoulos VK. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr
Surg . 2007;119(4):73e–92e.)
C2
C3
C4
C2
C3
C4
C5
C5 - Avulsion
C6 - Avulsion
C6
C7
Ax
Ax
Acc
Acc
MC
MC
Left LP
B
Reconstruction
Exploration
SS
M
R
A
C
D

684 • CHAPTER 57
pectoral nerve 57 or the thoracodorsal nerve 58 to the mus-
culocutaneous nerve. Leechavengvongs et al. 59 reported
excellent results with the long head of the triceps branch
transfer to the axillary nerve, achieving an average shoul-
der abduction of 124 degrees in his series. Furthermore, for
upper brachial plexus injuries, excellent results were vali-
dated by several authors with the Oberlin technique 13 , 60 , 61
in which a single redundant ulnar nerve fascicle (inner-
vating the fl exor carpi ulnaris) is transferred to the biceps
branch of the musculocutaneous nerve in the medial arm
to restore elbow fl exion. They also noted that hand and
ulnar nerve function, was not compromised during a long-
term follow-up period. The key aspect of the procedure is
to reinnervate the biceps branch of the musculocutaneous
nerve close to its motor entry into the muscle. Elbow fl ex-
ion function can be further augmented (especially in cases
of delayed surgery) by concomitantly reinnervating the
brachialis muscle by using a graft from the medial pectoral
nerve 62 or a fascicle of the adjacent median nerve. 63
Extraplexus Neurotization. In global root avulsions
where intraplexus donors are not available, reconstruction
is carried out by using only available extraplexus donors.
Global avulsion of the brachial plexus carries the worst
prognosis among all types of plexus lesions. The prime
goal is to restore shoulder stability, elbow fl exion, and
hand sensation. Extraplexus neurotization is the transfer
of a nonbrachial plexus nerve to distal plexus elements for
neurotization of a higher priority target. Options include
the distal spinal accessory nerve, the ipsilateral intercostal
nerves, the phrenic nerve, and motor branches of the cervi-
cal plexus (C3-C4).
The distal part of the spinal accessory nerve is used as
donor to preserve upper trapezius function. It is synergistic
with the suprascapular nerve, and direct repair is usually
possible. In our series, 81% of the distal spinal accessory to
the suprascapular nerve transfers were carried out directly,
without the need for an interposition nerve graft. The
outcomes were good and excellent in 79% of the patients
for the supraspinatus muscle and 55% for the infraspina-
tus muscle. 64 In our series, concomitant neurotization of
the axillary nerve yielded improved outcomes in shoulder
abduction function, as compared with repair of only the
suprascapular nerve. 65 The accessory nerve has also pro-
vided reliable results when used with an interposition graft
to the biceps. 66
Intercostal nerves have yielded acceptable results,
especially for reconstruction of the axillary, triceps, or
musculocutaneous nerve. 67 , 68 Intercostal nerves are chal-
lenging and time consuming to harvest, and each one has
approximately 1200 axons. When neurotization of the
musculocutaneous nerve is planned, which is composed
of approximately 6000 fi bers, at least three intercostal
nerves need to be used for this neurotization to yield an
acceptable result. 14 , 52 Intercostal nerves may also be used
to innervate a free muscle transplant. 18 , 69 in addition, their
sensory branches may be used separately for sensory neu-
rotization of the anesthetic hand.
Other options for motor donor nerves for reconstruc-
tion include the phrenic nerve and the contralateral C7
root. The phrenic nerve is considered to be a good motor
donor, with approximately 800 axons, but the risk of
potential long-term respiratory consequences should be
considered. 18 , 52 , 70 The senior author has used the proxi-
mal phrenic nerve for neurotization only if the patient
presents with a paralyzed diaphragm preoperatively. In
cases where all the ipsilateral intercostals are to be used
for neurotization procedures, the senior author’s prefer-
ence is to perform an end-to-side coaptation between the
phrenic nerve and a nerve graft, thereby preventing den-
ervation of the ipsilateral diaphragm. The phrenic nerve
can be directly coapted to the suprascapular nerve, or
used with an interposition nerve graft to the axillary or
musculocutaneous nerve. 71
The preliminary results of the contralateral C7 transfer
have been encouraging. 72 , 73 The contralateral C7 transfer
can be extended and enhanced by using a vascularized
ulnar nerve graft in patients with C8-T1 avulsions, and
the median nerve is the most common recipient. In our
series, median nerve neurotization yielded mostly protec-
tive sensibility and some return of the grasp in selected
patients. 50 A selective contralateral C7 technique was
introduced by the senior author. 12 Using microdissection
techniques, selective neurectomies deprive only certain
components of the C7 divisions (anterior division des-
tined for the pectoralis major and posterior division for
the latissimus dorsi and triceps) and rarely the entire
root. The functional motor and sensory donor defi cit
is minimal and recovers by 6 months. Neurotization of
single motor nerve using the selective contralateral C7
technique, such as the musculocutaneous, triceps branch,
and axillary nerve, yielded useful function in the majority
of patients. 50
The restoration of hand sensibility is of prime impor-
tance in global plexopathies and can be achieved by neu-
rotization of the median nerve from sensory intercostal
nerves or from the supraclavicular sensory nerves. A vascu-
larized ulnar nerve graft to the median nerve from either
intraplexus ipsilateral donors ( Figure 57-11 ) or from the
contralateral C7 root has been used to restore both sen-
sory protection and some fi nger fl exion. 48 Poor results are
caused by the long distances involved and the long dener-
vation time. To avoid misdirection, selective neurotization
of specifi c fascicles of the median nerve in the arm has
been proposed. 74 Nevertheless, in patients with complete
brachial plexus palsy, discriminatory sensibility is rarely
restored, but protective sensibility is useful for patients
with completely anesthetic hands. 75
Free Muscle Transplantation
Free functioning muscle transfer for brachial plexus
paralysis management 76 , 77 , 78 is a reconstructive option for
patients who have sustained complete brachial plexus
avulsions, for late cases, 79 or when the restored muscle

BRACHIAL PLEXUS • 685
FIGURE 57-11. A 32-year-old man sustained a global left brachial plexus paralysis following a motorcycle accident.
Preoperatively, he presented with a totally fl ail, anesthetic arm with severe, intolerable pain (A). The patient underwent an
exploration of his supraclavicular and infraclavicular left brachial plexus 6 months after the injury. The intraoperative diagnosis
was rupture of C5 root and avulsions of C6 to T1 roots. Plexus reconstruction included: accessory (Acc) to axillary nerve (AX)
with interposition nerve graft; direct neurotization of C4 motor branch to suprascapular (SS) nerve; and C5 to musculocutaneous
(MC), median (M), and posterior cord (PC) by means of a vascularized ulnar nerve graft. The patient also underwent secondary
procedures such as wrist fusion, free gracilis muscle transfer for fi nger extension, and free latissimus dorsi transfer for posterior
deltoid and triceps muscle substitution (B). Six years after the injury, he has strong elbow fl exion and fi nger fl exion through the
median nerve neurotization. The patient is able to lift easily his shoulder bag or a chair and he is currently pain free (C, D). (Part B:
From Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr
Surg. 1999:104(5):1221–1240.)
D
C
A
Acc
C3
C4
C4
C5
C5
Acc (+++)
MAC
SS
SS
U
M
M
MC
MC
PC
Ax
Ax
C6
Exploration
Reconstruction
C7
C8
T1
C6
C7
C8
T1
B

686 • CHAPTER 57
function after primary plexus reconstruction is deemed
inadequate. 14 , 18 Currently, free muscle transfers are per-
formed routinely for restoration of elbow fl exion 80 , 81 or
elbow extension and for reanimation of the hand. 82 – 84
Free muscle transfer of the contralateral latissimus dorsi
or the gracilis are the treatment of choice when muscles
from the ipsilateral side are not strong enough to support
elbow fl exion. In our center, the latissimus dorsi and the
rectus femoris muscles are considered the optimal muscles
to provide elbow fl exion or elbow extension. The trans-
ferred muscles are neurotized either directly from local
motor donors (ie, intercostal nerves) or by banked nerves
from ipsilateral motor donors, such as the accessory nerve
or cross-chest nerve grafts from the contralateral anterior
or posterior divisions of the C7 root. With such a transfer,
a functional outcome of at least M3 strength (antigravity)
can be achieved in the majority of cases (78%). 85
For hand reanimation, the gracilis muscle can also be
transferred to the forearm for fi nger fl exion or extension
or to substitute intrinsic muscle function. 14 , 18 Electro-
physiologic assessment of the free muscle transfer can
reveal contractions as early as 3 to 4 months, and a full
range of contraction can be expected at approximately 6 to
12 months. Transplantation of the gracilis muscle for fi n-
ger fl exion at the optimal resting tension, along with early
aggressive passive motion exercises, allow for grip strength
of 50% of normal. 86
Secondary Procedures
Additional procedures can be performed to facilitate
and augment specifi c functions in late cases where
the muscle targets have degenerated or when primary
reconstruction has not yielded satisfactory results. These
include tendon transfers, pedicled muscle transfers,
joint fusions, and a variety of osteotomies. 87 A common
tendon transfer for the shoulder is the transfer of the
clavicular and acromial insertion of the trapezius with
or without fascia lata to the deltoid insertion on the
humerus to enhance shoulder abduction and reverse
shoulder subluxation. 14 , 18 We do not advocate shoulder
arthrodesis as a therapeutic modality, because it permits
only a limited range of abduction and has a high inci-
dence of complications. 88
The restoration of elbow fl exion can be enhanced by
pedicled muscle transfer procedures. A variety of donor
muscles can be used: the latissimus dorsi, 14 the sterno-
clavicular part of the pectoralis major, the long head of
the triceps, and the Steindler fl exorplasty using the
fl exor-pronator musculature. 89 In patients with no wrist
function, arthrodesis of the wrist can improve comfort
or appearance and stabilize the wrist for hand use. 14 , 90
In our center, wrist fusion is usually performed simul-
taneously with a free muscle transfer for hand reanima-
tion. This allows a far more accurate setting of tension in
FIGURE 57-12. At the completion of surgery and before
extubation, a custom-made brace is applied to the patient’s
upper extremity. This brace keeps the arm abducted
45 degrees and in anterior fl exion, with the elbow fl exed.
the transferred muscle and thus further improvement of
hand function.
Postoperative Management
Complications of plexus reconstruction are rare and
include mainly localized wound infection and, very rarely,
pneumothorax during intercostal nerve harvesting. For the
latter, primary closure of the pleural defect can usually
be accomplished, but, occasionally, placement of a chest
tube may be necessary. Seroma formation after intercostal
nerves or latissimus dorsi muscle harvesting, as a result of
the extensive dissection, has been observed at times and
can be treated with needle aspiration and compression
dressing.
After the completion of surgery, the patient’s upper
extremity is immobilized in a custom-made shoulder
and elbow brace that keeps the arm abducted 45 degrees
with the elbow fl exed ( Figure 57-12 ). Usually, the patient
remains in the brace for 3 to 8 weeks depending on the
procedure followed by an arm sling. Physical therapy
begins at 6 weeks postoperatively and involves slowly
increasing the passive range of motion (ROM) at the dif-
ferent joints of the upper limb. Ultrasound, slow electrical
pulse stimulation, and massage are added for rehabilita-
tion to specifi c muscles. Self-ROM exercises are stressed to
avoid stiffness in the joints of the hand. The fi rst follow-up
visit is arranged at 3 and then at 6 months after surgery.
In cases of severe plexopathies with multiple avulsions,
ipsilateral reconstruction takes place in the fi rst procedure,
followed 3 months later by the selective contralateral C7
technique. After 1 year, the patient is evaluated fully for
return of function and plans for secondary reconstruction
are made at that time. Although rehabilitation is time con-
suming and many patients end up losing their motivation,

BRACHIAL PLEXUS • 687
this therapeutic process is mandatory as it eventually leads
to better physical and psychological outcomes.
OUTCOMES
To compare overall results from various large series, we
must consider the different group of patients, injuries,
surgeons, treatments, and grading scales. The prognosis is
highly dependent on the level and extent of injury. The
surgical repair is more effective for patients who sustain
infraclavicular lesions or for supraclavicular lesions when
at least two roots can be used for motor donors. 91 Kim et
al. 41 stated that repairs were best for injuries located at
the C5, C6, and C7 levels, the upper and middle trunk;
conversely, results were poor for injuries at the C8 and T1
levels, and/or for the lower trunk.
In our series 14 of 204 brachial plexus reconstructions it
was shown that intraplexus donors, when they are avail-
able, resulted in the strongest power, regardless of the
muscle target. However, some of the extraplexus donors
gave consistently superior results when they neurotized
specifi c targets directly. Direct neurotization of the supras-
capular nerve from the distal accessory nerve yielded com-
parable results to repair with intraplexus donors. Overall,
in our series, 79% of patients achieved good and excel-
lent shoulder abduction (muscle grade, 13 or higher),
and 55% of patients achieved good or excellent shoulder
external rotation after reinnervation of the suprascapular
nerve. 64 The best results were seen when direct neuroti-
zation of the suprascapular nerve from the spinal acces-
sory nerve or neurotization by the C5 root was carried out.
Concomitant neurotization of the axillary nerve yielded
improved outcomes in shoulder abduction and external
rotation function. 65
Merrell et al., 92 in a meta-analysis of the English-language
literature regarding neurotizations for restoration of the
shoulder and elbow function, suggest that interposition
nerve grafts should be avoided whenever possible when
performing nerve transfers. Better results for restoration of
elbow fl exion have been obtained with direct intercostal
to musculocutaneous transfers than with spinal accessory
nerve transfers, which requires a nerve graft; and direct spi-
nal accessory to suprascapular transfers appear to have the
best outcomes for return of shoulder abduction. The use
of intercostal nerves to directly neurotize the musculocu-
taneous nerve continues to be a standard approach in the
reconstruction of severe plexus lesions. Direct neurotiza-
tion is equally effective and less demanding than transfers
involving interposition nerve grafts. Different studies have
reported good function of the biceps (M31 and higher)
after neurotization with intercostals for 64% to 87% of
patients. 67 , 68
In the grim scenario of global avulsion, the addition of a
contralateral C7 transfer with an interposition vascularized
ulnar nerve graft directed to the median nerve or the mus-
culocutaneous nerve, good results can be expected in
almost 60% patients. 14 , 93 Alternatively, some lower sen-
sory intercostal nerves or cervical plexus elements can
be directed to the sensory portion of the median nerve.
With this transfer strategy, the majority of the patients will
recover protective sensation. In cases of lower root involve-
ment, it is a smart strategy to leave banked nerves at the
elbow level either from ipsilateral donors or from the con-
tralateral C7 root by using the selective contralateral C7
technique 12 for future free muscle transplantation for hand
reanimation. The reconstruction of these devastating and
time-consuming injuries usually involves multiple stages
of reconstruction with an extended postoperative course
of intensive physical rehabilitation. Pain management
should be addressed early and the denervation time should
be minimized to improve the prognosis. Despite the com-
plexity of the surgical procedures and the extended recov-
ery period, brachial plexus palsy has considerably evolved
with improved functional outcomes, allowing the patient
to lead a productive and satisfying life. 15
CONCLUSION
The surgical management of these severe injuries demands
a deep understanding of the brachial plexus and comfort
with the current available techniques which can lead in
the evolvement of further reconstructive strategies and
improved prognosis. Radiographic and electrophysiologic
studies are of great assistance in a preoperative and intra-
operative evaluation, contributing to a more thorough
study of root avulsion of the brachial plexus. Use of novel
extraplexus donor nerves, selective neurotizations, and free
muscle transfers are all modern surgical procedures that
can offer satisfactory outcomes even in multiple avulsion
injuries. Nerve grafting or nerve transfer is more rewarding
when the distal coaptation is near the muscle target. The
current trend is toward targeting the donor nerves for spe-
cifi c muscles directly; the more specifi c the target, the less
misdirection of the donor fi bers and, therefore, the muscle
target reinnervation is maximized.
Future developments will attempt to apply neurosci-
ence research dealing with neurotrophic growth factors to
accelerating the regeneration “clock.” Avulsed root reim-
plantation into the spinal cord may be assisted by a bet-
ter understanding of the neuronal pools of fl exor versus
extensor musculature, thus avoiding the “paralyzing” co-
contractions. Stem cell manipulation may restore the loss
of the motor neurons that follows proximal injuries and
lead to a new era of upper limb functional rehabilitation.
Finally, distal target atrophy and loss may be prevented
from implanted “micropacemakers” that will maintain the
muscle by a volley of stimuli until the regenerating axon
makes the critical distal connection.

688 • CHAPTER 57
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690 • CHAPTER 57
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c h a p t e r
Dupuytren’s Disease
Andrew J. Watt, MD / James Chang, MD
INTRODUCTION
A Dupuytren contracture is a progressive disease of the
palmar and digital fascial structures of the hand, charac-
terized by nodular thickening and subsequent contracture.
Deformity occurs primarily at the metacarpophalangeal
(MCP) and proximal interphalangeal (PIP) joints resulting
in functional disability. The disease process presents a for-
midable challenge to hand surgeons because of distortion
of the native anatomy and the recalcitrant nature of the
underlying pathologic process.
Early descriptions of Dupuytren’s disease attributed
the hand contractures to fl exor tendon involvement.
Dupuytren himself did not dispel this belief until 1831
when he described the disease process as affecting the
aponeurotic tissue of the palm, sparing the fl exor tendons
themselves. 1 The etiology and pathogenesis of Dupuytren’s
disease remained a matter of both speculation and inciden-
tal correlation. It has been only over the past 25 years that
surgeons and scientists have begun to unravel the underly-
ing mechanisms that contribute to the development of the
disease. Despite these advances, our current understanding
of the disease process remains incomplete.
Dupuytren’s disease belongs to the overarching cat-
egory of benign superfi cial fi bromatoses and, as such, is
closely related to Peyronie disease (penile fi bromatosis) and
Lederhosen disease (plantar fi bromatosis). Histologically,
the affected tissue is characterized by nodular rests of
myofi broblasts surrounded by dense collagen. Molecular
analysis reveals a preponderance of type III collagen,
which is not typically observed in mature palmar fascia,
and increased concentrations of prostaglandins, as well
as several subtypes of transforming growth factor beta. 2 , 3
The presence of CD-31 T cells has also been noted rais-
ing the question of immunologic involvement. The exact
role of these factors in the pathogenesis of Dupuytren’s
disease as well the underlying diathesis remain a matter
of supposition at the current time. Despite this ambiguity
in the underlying cause of Dupuytren’s disease, the course
of disease progression has been well described. In 1959,
Luck described the pathogenesis of Dupuytren contrac-
ture in pathologic terms consisting of proliferative , involu-
tional , and residual phases. The disease process progresses
from an early proliferative phase with the formation of
myofi broblast-rich nodules in the palmar and digital fascia.
These nests of myofi broblasts actively deposit disorganized
type III collagen. The myofi broblasts reorganize, differenti-
ate, and align along the lines of tension during the involu-
tional phase. During the residual phase, contraction occurs
with the development of thickened cords of diseased fas-
cia. 4 The cumulative effect is transformation of the normal
fascial bands to fi brotic, diseased cords.
EPIDEMIOLOGY
The overall incidence of Dupuytren’s disease varies accord-
ing to the population studied, with published rates rang-
ing between 2% and 42%. 5 The incidence is highest among
individuals of northern European ancestry. The disease is
rare in individuals of African or Asian descent; however,
there are isolated populations in Japan and Taiwan that
maintain a disease incidence comparable to that of north-
ern Europeans. Men are 6 times more likely to develop
Dupuytren’s disease than are women. 6 The disease onset
is primarily in the fi fth decade of life for men, and the
sixth decade for women. Bilateral disease occurs in 59% of
affected men and 43% of affected women.
Population studies support an autosomal dominant
inheritance pattern with variable penetrance. Among male
relatives with an affected proband, 68% develop the dis-
ease at some point in their lifetimes. 5 Associations with
repetitive trauma, alcohol abuse, hepatic disease, diabetes
mellitus, smoking, chronic obstructive pulmonary disease,
58

692 • CHAPTER 58
HIV, and malignancy (paraneoplastic manifestation) have
been proposed. 7 - 9 Patients with Dupuytren’s disease clearly
demonstrate an increased incidence of both penile and
plantar fi bromatosis.
PATIENT EVALUATION AND SELECTION
Patient Presentation and Diagnosis
Patients may present with fi ndings that encompass the
spectrum of the disease progression, and the diagnosis is
made based on the history and clinical examination. The
earliest sign of the disease may consist of a puckering of
the dermis overlying the fl exor tendon just distal to the
distal palmar crease. This pit, or dimpling of the skin, cor-
responds with the attachment of the longitudinal fi bers
of the palmar aponeurosis as they insert into the overly-
ing dermis. As the disease progresses and the underlying
aponeurosis becomes increasingly fi brotic, a discrete nod-
ule or nodules become distinctly palpable overlying the
fl exor tendon. Gradually, over the course of years, MCP
joint contracture develops, followed, in more severe cases,
by PIP joint contracture. With severe contracture of the
palm, maceration of the skin may also occur at the distal
palmar crease ( Figure 58-1 ).
FIGURE 58-1. Characteristic appearance of Dupuytren’s
disease.
Nodules and contraction may occur throughout the pal-
mar and digital fascia; however, particular regions of the
fascia are prone to disease. The ring fi nger is most com-
monly affected, followed in prevalence by the small fi nger,
thumb, middle, and index fi ngers. The presence of nod-
ules is paramount to the diagnosis of Dupuytren’s disease.
These nodules are fi rm to palpation and may be tethered
to the overlying dermis. Nodules in the palm are princi-
pally located at the distal palmar crease, and nodules in
the digital fascia occur in proximity to the PIP joint. Over
time, the nodules involute, leaving chordal structures in
the residual phase of the disease process. Although patients
may initially present with a painful palmar nodule, it is
important to note that this pain will typically subside over
time.
Patients may also present with Garrod nodules, or
knuckle pads, located dorsally over the PIP joints. Garrod
nodules may be associated with a higher likelihood of
bilateral hand involvement; however, their presence does
not suggest stage or severity of disease, nor do they result
in any functional limitation themselves. 10 The presence of
knuckle pads, however, is not necessarily associated with
a higher incidence of concomitant fi bromatoses, including
Peyronie and Lederhosen diseases.
The diagnosis of Dupuytren’s disease is based solely on
the history and physical examination. The characteristic
progression from nodule to fi brotic cord with contrac-
ture of the affected palm and digits is pathognomonic for
Dupuytren’s disease. The history is often signifi cant for an
insidious onset with progressive contracture and disability
developing over the course of years. Hand radiographs are
generally unnecessary to rule out dystrophic calcifi c com-
ponent or osseous involvement unless clinical suspicion
is high that an underlying arthritis exists. The differen-
tial diagnosis may include camptodactyly, traumatic scars,
Volkmann ischemic contracture, intrinsic joint arthrosis,
locked trigger fi nger, and spastic digital contracture. These
diagnoses may be separated based on the history and phys-
ical examination.
Surgical Indications and Contraindications
The primary objective of treatment in patients with
Dupuytren’s disease is correction of the deformity, thereby
reducing disability and restoring hand function. It there-
fore follows that the degree of joint contracture and, more
importantly, the extent of functional disability are the
primary indications for intervention. Although promis-
ing interventional treatments, including enzymatic lysis of
diseased tissue with collagenase and percutaneous needle
aponeurotomy, are emerging, the contemporary treatment
remains primarily surgical. The presence of a nodule alone
is not suffi cient to justify surgical intervention. The com-
monly accepted surgical indications include greater than
30 degrees of MCP joint contracture, and any degree of
PIP joint contracture, as these degrees of contracture are
commonly cited as functionally limiting. 11

DUPUYTREN’S DISEASE • 693
Surgical intervention for a MCP joint contracture is
not urgent since the collateral ligaments are taut in MCP
joint fl exion, and this position is protective with respect
to joint motion. Surgical intervention may therefore be
delayed without compromising the functional outcome. In
contrast, a PIP joint contracture requires an early surgical
release because they are more resistant to correction. A
long-standing PIP joint contracture precipitates articular
changes with a loss of subchondral bone and a fi xed fl exion
contracture of the joint. In an effort to preserve functional
PIP joint motion, surgery is indicated with any degree of
contracture. Additional indications for operative interven-
tion include a fi rst web adduction contracture, an unremit-
ting tenosynovitis secondary to a palmar nodule overlying
the A1 pulley, and palmar contracture resulting in macera-
tion at the distal palmar crease.
Few contraindications to surgery exist beyond those con-
siderations that would preclude regional or general anes-
thesia. Poor operative candidates include those patients
with long-standing PIP joint contracture and documented
underlying articular changes. These patients may require a
PIP joint arthroplasty or joint fusion in more severe cases.
Even in patients without notable articular changes, full PIP
extension is diffi cult to achieve. In addition, patients who
describe pain as their primary symptom and patients who
smoke are poor operative candidates.
PATIENT PREPARATION
Preoperative Considerations
Patient preparation consists of preoperative evaluation and
counseling combined with a discussion of the operative
choices. The preoperative evaluation should include a com-
prehensive history and physical examination in addition
to a thorough hand examination. Although rare, patients
should be evaluated for Dupuytren diathesis as well.
Dupuytren diathesis refers to a predisposition to bilateral
early onset disease, typically before the age of 40 years,
rapid progression, ectopic manifestations, including dorsal
knuckle pads, and penile as well as plantar fi bromatosis.
Clinicians may also choose to document disability with
hand-specifi c questionnaires such as the DASH Outcome
Measure or Michigan Hand Outcomes Questionnaire as
a reference for postoperative comparison. Operative cor-
rection of Dupuytren’s disease can be performed with
an infraclavicular or axillary block for analgesia, and may
be supplemented with local anesthetic and sedation.
Anticoagulant and antiplatelet agents should be held at least
7 days prior to surgery in an effort to reduce the incidence
of postoperative palmar hematoma. Ideally, patients who
smoke should undergo a smoking cessation program prior
to surgery. The critical component of patient preparation
involves a discussion of the postoperative course, potential
complications, and expected outcomes. Most importantly,
the hand surgeon should discuss the progressive and per-
sistent nature of the disease process, emphasizing that sur-
gical intervention remains a method of temporizing the
disease progression and improving hand function rather
than providing a cure for Dupuytren’s disease.
Operative Considerations
Patients should be positioned supine with the affected
extremity supinated and abducted on a hand table. A
surgical tourniquet should be placed on the arm, and the
arm exsanguinated with an Esmarch wrap. The extrem-
ity should be prepped circumferentially, and a sterile lead
hand may be utilized to obtain digital extension with ade-
quate exposure of the palm.
The choice of the operative technique for the correc-
tion of Dupuytren contracture is the subject of much
debate and is dependent on the individual surgeon’s train-
ing and an understanding of the progression of the disease
process. Operative techniques range from fasciotomy to
subcutaneous fasciectomy, limited fasciectomy, regional
fasciectomy, radical fasciectomy, and dermatofasciectomy
( Table 58-1 ). The latter techniques differ primarily in the
extent of palmar dissection.
A fasciotomy consists of disruption of the diseased cords,
which may be performed either percutaneously or through
limited incisions overlying the diseased cords. A fasciotomy
does not address the nodular component of the disease
process. A subcutaneous fasciectomy minimizes the pal-
mar dissection by relying on disruption of the continuity of
the palmar aponeurosis and includes resection of discrete
Dupuytren nodules. These procedures involve limited dis-
section minimizing the risk of postoperative complications
including hematoma; however, outcomes data show that
postoperative correction of joint contracture is not main-
tained at 3 years. 12 The majority of surgeons reserve these
TABLE 58-1. Surgical Options for the
Treatment of Dupuytren’s Disease
Surgical Technique
Description
Fasciotomy
Division of diseased cords
without excision
Local fasciectomy
Removal of segment of
diseased cord
Regional fasciectomy
Removal of all diseased fascia
as well as local region of
grossly normal tissue
Radical fasciectomy
Removal of the entire palmar
and digital fascia
Open palm technique
(McCash 14 )
Division of the palmar
aponeurosis without closure
of the skin defi cit created
Dermatofasciectomy
Removal of the diseased fascia
as well as the overlying skin.
Closure typically obtained
with the use of a full-
thickness skin graft

694 • CHAPTER 58
operations for elderly patients with systemic disease who
may poorly tolerate a more extensive operation.
Limited fasciectomy removes a portion of the diseased
aponeurosis, disrupting continuity of the diseased tis-
sue and resecting aponeurotic tissue associated with the
affected digits. This procedure is a compromise between
removal all of the diseased aponeurosis, so that recurrence
cannot take place, and local excision. Limited fasciectomy
limits palmar dissection while effectively addressing the
underlying pathology.
Regional fasciectomy is appropriate for the majority of
patients upon primary presentation and has become the
standard of care for most hand surgeons. Regional fasciec-
tomy consists of removal of all of the diseased aponeuro-
sis coupled with resection of a margin of normal palmar
aponeurosis. All nodules are resected and digital dissection
is performed to address proximal and distal interphalan-
geal contracture. This procedure limits the risk of disease
recurrence while avoiding the morbidity of a radical palmar
dissection.
In a radical fasciectomy one strives to remove the entire
palmar aponeurosis in an effort to prevent palmar recur-
rence. This operation is effective in minimizing palmar
recurrence; however, the incidence of palmar hematoma
increases with the extent of dissection. Given that disease
recurrence is typically digital rather than palmar, most
hand surgeons reserve radical fasciectomy for patients with
Dupuytren diathesis and those with recurrent disease.
Dermatofasciectomy involves resection not only of the
aponeurosis, but also the overlying skin with placement of a
full-thickness skin graft. Dermatofaciectomy is commonly
reserved for patients with recurrent palmar disease.
The specifi c operative approach is determined by the
extent of palmar skin involvement, the presence of MCP
and PIP joint contracture, and the digit involved.
OPERATIVE TECHNIQUE
Anatomy
Proper surgical intervention for Dupuytren’s disease
requires a detailed understanding of both the normal
palmar and digital fascial anatomy, which by convention
are termed bands, as well as the pathologic progression
of the involved fascial structures, which are termed dis-
eased cords. The diseased cords are the result of pathologic
change in the normal fascial structures and therefore their
anatomic confi gurations and relationships are predictable
( Table 58-2 ). In addition, the surgeon must consider that
the disease process is itself both visible, as discrete nod-
ules, and microscopic, in apparently grossly normal tissue.
Consequently, the treatment includes a resection of both
involved and potentially involved fascial structures.
Affected structures include the palmar aponeurosis and
its digital extensions (pretendinous bands) as well as the
digital fascia, natatory ligament, Grayson ligament, spiral
TABLE 58-2. Diseased Cords in Dupuytren’s Disease
Diseased Structure
Anatomic Origin
Clinical Signifi cance
Palmar Cords
Pretendinous cord
Pretendinous band
MCP joint fl exion contracture
Vertical cord
Vertical fi bers of McGrouther or septa
of Legueu and Juvara
Causes painful triggering
Palmodigital Cords
Spiral cord
Pretendinous band, spiral band,
lateral digital sheet, Grayson ligament
Displaces the neurovascular bundle medially
and superfi cially (spiral nerve)
Natatory cord
Natatory ligament (distal fi bers)
Web space adduction contracture
Digital Cords
Central cord
Pretendinous cord (digital extension)
PIP joint fl exion contracture
Retrovascular cord
Retrovascular band of thomine
PIP and DIP joint fl exion contracture; prevents
full correction of PIP joint contracture
Lateral cord
Lateral digital sheet (often closely
associated with pretendinous and
natatory cord)
PIP and DIP joint fl exion contracture; displaces
neurovascular bundle medially
Abductor digiti minimi cord
Abductor digiti minimi tendon
PIP joint fl exion contracture
Thumb and First Web Space Cords
Proximal commissural cord
Proximal commissural ligament
First web adduction contracture
Distal commissural cord
Distal commissural ligament
First web adduction contracture
Thumb pretendinous cord
Pretendinous band
MCP joint fl exion contracture
MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal.

DUPUYTREN’S DISEASE • 695
band, and retrovascular fascia ( Figure 58-2 ). The superfi -
cial transverse palmar ligament is predominantly spared;
however, involvement at its radial extent as it inserts into
the base of the thumb may occur, resulting in adduction
contracture of the fi rst web space. Cleland ligaments are
spared in the disease process.
The operative approach and extent of dissection is
determined by the extent of palmar skin involvement, and
the degree of MCP and PIP joint contracture. Successful
operative intervention is predicated on an understanding
of which disease components contributes to contracture
at these locations. Palmar skin contracture results from
involvement of the palmar aponeurosis itself, and is cor-
rected with a partial or complete palmar aponeurectomy.
MCP joint contracture results solely from involvement of
the pretendinous bands, and is likewise addressed with a
palmar aponeurectomy and excision of the diseased pre-
tendinous cords. Several anatomic components contribute
to PIP joint contracture. The digital fascia gives rise to the
pretendinous and lateral cords. The pretendinous, spiral,
and lateral bands coalesce with Grayson ligament to form
the pathologic spiral cord ( Figure 58-2 ), and the retrovas-
cular fascia forms the retrovascular cord. 13 Each of these
pathologic cords, either alone or in combination, result
in PIP joint contracture. They must be excised to prevent
progression or recurrence of contracture.
Adduction contracture of the thumb as well as abduc-
tion contracture of the small fi nger deserve special atten-
tion and are addressed uniquely. Akin to contracture of the
fi ngers, an adduction contracture of the thumb results from
involvement of the pretendinous band and the natatory
ligament; however, involvement of the radial aspect of the
superfi cial transverse ligament of the palm as it inserts into
the skin at the base of the thumb coupled with the forma-
tion of proximal and distal commissural cords results in an
adduction contracture of the fi rst web space. This situation
is unique as the superfi cial transverse ligament of the palm
is spared throughout the remainder of its course. These
structures lie superfi cial to the neurovascular bundle and
resection remains straightforward. Dupuytren’s disease
also characteristically results in an abduction contracture of
the small fi nger. The pretendinous, spiral, and retrovascular
Grayson’s
ligament
Neurovascular
bundle
Natatory
ligament
Pretendinous
band
Common
digital a.
Cleland’s
ligament
Lateral
digital sheet
Spiral band
Transverse
fibers of
palmar
aponeurosis
Spiral cord
Central cord
Lateral cord
Natatory cord
Pretendinous cord
Common
digital n.
FIGURE 58-2. (A) Palmar and digital fascial structures involved and spared by
Dupuytren’s disease. Involved structures include the pretendinous band, spiral band,
natatory ligament, lateral digital sheet, and Grayson’s ligament. Spared structures include
Cleland’s ligament and the transverse fi bers of the palmar aponeurosis. (B) Formation
of the spiral cord from the pretendinous band, spiral band, lateral digital sheet, and
Grayson’s ligament. Note the spiral cord displaces the neurovascular bundle medially,
superfi cially and proximally. (From Mcfarlane RM. Patterns of the diseased fascia in the fi ngers in
Dupuytren contracture. Plast Reconstr Surg . 1974;54:31–44, with permission.)
A
B

696 • CHAPTER 58
cords all contribute to fl exion contracture; however, it is
the lateral cord, coursing along the ulnar aspect of the
small fi nger that contributes to the abduction.
Incision
The diseased digital and palmar fascia may be approached
through a variety of incisions, either separately or in con-
junction (Figure 58-3). The diseased aponeurosis may be
approached through a transverse palmar incision. This
incision begins in the distal palmar crease at the ulnar
aspect and ends in the proximal palmar crease on the
radial aspect. The transverse palmar incision provides
access to the entire palmar aponeurosis and may be modi-
fi ed according to the segment of the aponeurosis to be
resected. Alternatively, longitudinal incisions are useful for
digital exposure and may be extended into the palm for
exposure of the aponeurosis. A longitudinal incision with
z-plastys at the fl exion creases or a zig-zag Bruner-type
incision both provide excellent exposure. Closure with a
FIGURE 58-3. Incisions utilized in surgery for
Dupuytren’s disease. The thenar contracture is addressed
throught a T incision with z-plastys at the fl exion creases. The
middle fi nger demonstrates a modifi ed Bruner incision with
Y-V advancement. The ring fi nger demonstrates a traditional
Bruner incision. The small fi nger demonstrates a longitudinal
incision with z-plastys at the fl exion creases.
FIGURE 58-4. Intraoperative dissection of spiral
cord. Note displacement of the neurovascular structures
proximimally, medially, and superfi cially.
Y-V advancement fl ap provides for additional length and
is particularly useful in patients with signifi cant contrac-
ture in which a relative defi ciency of skin exists upon cor-
rection of the contracture. A contracture of the fi rst web
space is best approached through a T incision combined
with a z-plasty to prevent scar contracture
Dissection
After the skin is incised, it is sharply dissected off the
cord in the palm region. Proximal to the MCP joint, the
digital neurovascular structures are safe, deep to the cord
itself and are therefore protected. With the cord skeleton-
ized, the digital nerves and arteries may be identifi ed and
traced distally. All abnormal tissue is excised, including the
involved vertical fi bers of Legueu and Juvara. Once the
palmar aponeurosis and pretendinous cords have been dis-
rupted, the MCP joints will extend without constraint. In
the fi nger, meticulous care is exercised in order to avoid
damage to a medially and superfi cially displaced neurovas-
cular bundle resulting from the presence of a spiral cord
( Figure 58-4 ). The presence of a spiral cord should be sus-
pected in all patients; however, clues to its presence include
a PIP joint contracture accompanied by prominence of the
skin just proximal to the proximal digital crease.
Surgical correction of PIP joint involvement requires
a digital dissection with resection of the central, lateral,
spiral, and retrovascular cords. It is safest to incise distal
to the cord, within normal tissue, in order to safely iden-
tify the digital neurovascular structures. Once the digital
arteries and nerves have been identifi ed, it is possible to
trace the neurovascular bundles proximally and distally.
Dissection is also carried laterally, exposing the lateral cord
in a distal to proximal fashion in order to protect the dis-
placed neurovascular structures. The lateral cord is derived
from the lateral digital fascia and is markedly adherent to
the dermis. Fibers of the lateral cord extend distally to the

DUPUYTREN’S DISEASE • 697
distal phalanx and, in severe cases of Dupuytren’s disease,
are responsible for a distal interphalangeal joint contrac-
ture. The dissection must therefore be carried distally to
its insertion on the lateral aspect of the distal phalanx.
Attention is then turned to the spiral cord which is in
proximal continuity with the pretendinous cord, travels
deep to the neurovascular bundle, and spirals superfi cially
to insert at the base of the middle phalanx.
Contracture of the thumb and the small fi nger are
addressed similarly. An adduction contracture of the
thumb is not uncommon and is addressed with resec-
tion of the pretendinous cord, natatory ligament, and the
radial extent of the superfi cial transverse ligament of the
palm as it inserts into the dermis at the base of the thumb.
An abduction contracture of the small fi nger is addressed
with both palmar and digital dissection as described for
the index, middle, and ring fi ngers. In addition, the muscle
belly of the abductor digiti minimi is exposed and its inser-
tion into the ulnar lateral band is excised.
Wound Closure
The method of closure varies according to tissue availabil-
ity as well as the incision itself. Transverse incisions may be
left open and allowed to heal via secondary intention, as
advocated by McCash 14 or a full-thickness skin graft may be
used to achieve durable closure. If suffi cient tissue exists to
achieve primary closure of the transverse incision, sutures
may be used to approximate the wound edges. For digital
closure, longitudinal incisions are closed with z-plastys at
the fl exion creases. Zig-zag Bruner-type incisions are ame-
nable to primary closure by incorporating a Y-V advance-
ment fl ap for increased length. The surgical wound should
be closed with 5-0 nylon or absorbable sutures.
Postoperative Care
Postoperative care is based on the maintenance of fi nger
extension and early mobilization in an effort to prevent early
recurrent contracture and joint stiffness. Postoperatively,
patients should be placed in a volar splint with the MCP
and PIP joints in extension. This splint is removed on post-
operative day 5. At that time, the wound is also examined
for signs of infection or dehiscence. The patient is begun on
an active range of motion regimen, and is provided with a
night-time extension splint which is worn for 4 to 6 weeks.
The sutures are removed on postoperative day 20, allow-
ing for adequate wound healing.
COMPLICATIONS
Complications in the surgical treatment of Dupuytren’s
disease may be categorized as operative, early and late.
Operative complications most commonly involve dam-
age to the neurovascular bundle as a consequence of their
medial and superfi cial displacement by a pathologic spiral
band. Experienced surgeons have reported rates of arterial
and nerve injury less than 0.4% and 2.3%, respectively. 15
Damage to the neurovascular bundle may be avoided by
maintaining a high suspicion in all patients and particularly
in those patients with PIP joint contracture. Dissection
between the distal palmar crease and proximal digital
crease should be directed at identifying and preserving
the neurovascular bundles. A nerve or vascular laceration
should be repaired should it occur. The surgeon should
be particularly vigilant during reoperation for recurrent
contracture as the digit may be supplied by a single digi-
tal artery. Digital ischemia is addressed intraoperatively
by (1) minimizing compression from skin closure and
dressings; (2) infi ltrating agents (papaverine, lidocaine)
to decrease vasospasm; (3) decreasing extension of the
digit to prevent unaccustomed stretch on the digital ves-
sels; and lastly, (4) microsurgical exploration and repair as
necessary.
Early complications include infection, hematoma, skin
necrosis, and postoperative fl are reaction. Postoperative
wound infection typically occurs in 1% to 4% on patients,
but has been reported to be as high a 9.5%. 15 This high inci-
dence is likely attributable to bacterial overgrowth within
the macerated distal palmar crease as well as to the tenuous
blood supply to the palmar fl aps. Another common com-
plication of palmar dissection is postoperative hematoma
which often results in palmar skin necrosis if not identi-
fi ed and evacuated. The reported incidence in populations
undergoing a variety of surgical techniques is 2%; however,
the risk with radical fasciectomy is signifi cantly higher. 15
The risk of palmar hematoma may be minimized by
obtaining hemostasis with the tourniquet defl ated, prior to
application of the fi nal dressing, and by minimizing palmar
dissection. Some authors advocate application of a pres-
sure dressing; however, this intervention is unnecessary if
meticulous operative hemostasis is obtained. The incidence
of palmar hematoma may also be reduced with the use
of the open palm technique of McCash. 14 Postoperative
fl are reaction may also occur, consisting of signifi cant pain,
swelling, and joint stiffness, characteristically occurring in
the third to fourth week following surgery. Flare reaction is
signifi cantly more common in women and its incidence is
further increased with concomitant procedures, including
carpal tunnel release. 15 , 16 For this reason, multiple proce-
dures should not be performed at time of operation for
Dupuytren’s disease. This syndrome may be a precursor
of complex regional pain syndrome, and the incidence is
minimized with the use of axillary or infra/supraclavicular
regional anesthesia.
Late complications include complex regional pain syn-
drome, scar contracture, and disease recurrence or, more
appropriately, disease progression. Complex regional
pain syndrome refers to a syndrome characterized by
pain, allodynia, and hyperalgesia disproportionate to the
extent of inciting injury accompanied by evidence of
vasomotor instability. This syndrome includes both refl ex
sympathetic dystrophy and causalgia. The incidence of
complex regional pain syndrome in patients undergo-
ing fasciectomy for Dupuytren’s disease ranges between
4.5% and 40%, and varies on the choice of anesthetic.

698 • CHAPTER 58
Regional analgesia provides the lowest postoperative inci-
dence, with comparable results achieved with intravenous
regional anesthesia accompanied by clonidine. The high-
est reported incidence occurs with general anesthesia. 17
For this reason, infraclavicular or axillary block should be
considered the anesthetic method of choice when operat-
ing for Dupuytren’s disease. Scar contracture occurs with
longitudinal digital incisions with a reported incidence of a
1% in the literature. The risk of contracture may be mini-
mized by using z-plastys at the fl exion creases, or Bruner
incisions. Prolonged postoperative stiffness is reported
in 10% of patients. 18 The most common complication of
Dupuytren’s disease is recurrence. The incidence of recur-
rence varies with technique and ranges between 32% and
40% with open techniques, 19 , 20 and is reported to be as
high as 58% with percutaneous transection of the diseased
cords. 20 In general, recurrence may be minimized with
appropriate digital dissection coupled with more extensive
palmar dissection. The benefi ts of more extensive dissec-
tion must, however, be weighed against higher incidence
of wound complications. Recurrence does not invariably
require additional surgery. Rodrigo and colleagues 21 found
that 15% of patients required reexcision following disease
recurrence.
OUTCOMES ASSESSMENT
Numerous studies exist demonstrating the effective-
ness of digital and palmar fasciectomy in restoring MCP
and PIP joint extensions. Extension at the MCP joint
may be reliably restored to within 15 degrees of normal
irrespective of the extent preoperative contracture. PIP
extension, in contrast, is adversely affected by both the
degree and duration of contracture, but may be reliably
corrected to within 30 degrees of normal. Restoration of
form may be reliably achieved in all but the most severe
cases of contracture; however, restoration of function
remains the primary objective of surgical intervention in
Dupuytren’s disease. Despite an extensive body of liter-
ature, few studies have been undertaken to demonstrate
that restoration of form improves hand function, and no
studies exist effectively quantifying patient satisfaction
with postoperative outcomes. Sinha and colleagues 22
have objectively studied the correlation between pre-
and postoperative deformity with functional outcome.
They objectively demonstrated that an increasing hand
deformity at the MCP and PIP joints correlated with
increasingly poor hand function. They further showed
that hand function was most dependent on the degree
of deformity at the PIP joint. With the establishment
of this correlation, they showed that surgical correc-
tion of deformity results in a signifi cant improvement
in hand function, and is particularly dependent on the
correction of PIP joint deformity. Operative outcomes
are tempered by the high incidence of disease recur-
rence despite the best available surgical management.
Therefore, a role for novel therapies as well as adjuvant
treatment exists. Ongoing efforts are gradually elucidat-
ing the underlying biochemical mechanisms underly-
ing Dupuytren’s disease, and will likely provide unique
therapeutic targets to supplement or even replace oper-
ative therapy.
REFERENCES
1. Dupuytren G. Permanent retraction of the fi ngers produced
by and affectation of the palmar fascia. Lancet . 1834;2:
222–225.
2. Kloen P, Jennings CL, Gebhardt MC, et al. Transforming
growth factor-beta: possible roles in Dupuytren’s contrac-
ture. J Hand Surg Am . 1995;20(1):101–108.
3. Kloen P. New insights in the development of Dupuytren’s
contracture: a review. Br J Plast Surg . 1999;52(8):629–635.
4. Luck JV. Dupuytren’s Contracture. A new concept of
the pathogenesis correlated with the surgical management.
J Bone Joint Surg (Am) . 1959;40(4):635–664.
5. Ling R. The genetic factor in Dupuytren’s disease. J Bone
Joint Surg (Br ). 1963;45:709–718.
6. Wilbrand S, Ekbom A, Gerdin B. The sex ratio and rate of
reoperation for Dupuytren’s contracture in men and wom-
en. J Hand Surg Am . 1999;24B:456–459.
7. Liss GM, Stock SR. Can Dupuytren’s contracture be work
related? Review of the evidence. Am J Ind Med . 1996;29(5):
521–532.
8. Burge P, Hoy G, Regan P, Milne R. Smoking, alcohol, and the
risk of Dupuytren’s contracture. J Bone Joint Surg Br . 1997;
79:206–210.
9. Leslie BM. Palmar fasciitis and polyarthritis associated with
malignant neoplasm: a paraneoplastic syndrome. Orthope-
dics . 1992;15(12):1436–1439.
10. Caroli A, Zanasi S, Marcuzzi A, et al. Epidemiology and
structural fi ndings supporting the fi bromatous origin of dor-
sal knuckle pads. J. Hand Surg Br . 1991;16:258–262.
11. Hueston JT. Current state of treatment of Dupuytren’s
disease. Ann Chir Main. 1984;3(1):81–92.
12. Colville J. Dupuytren’s contracture: the role of fasciotomy.
Hand. 1983;15(2):162–166.
13. McFarlane RM. Patterns of diseased fascia in the fi ngers
in Dupuytren’s contracture. Plast Reconstr Surg . 1974;54:
31–44.
14. McCash CR. The open palm technique in Dupuytren’s con-
tracture. Br J Plast Surg . 1964;17:271–280.
15. Bulstrode NW, Jemec B, Smith PJ. The complications of
Dupuytren’s contracture surgery. J Hand Surg Am . 2005;
30(5):1021–1025.
16. Zemel NP. Dupuytren’s contracture in women. Hand Clin .
1991;7(4):707–711.

DUPUYTREN’S DISEASE • 699
17. Nissenbaum M, Kleinert HE. Treatment considerations in
carpal tunnel syndrome with coexisting Dupuytren’s dis-
ease. J Hand Surg Am . 1980;5(6):544–547.
18. Reuben SS, Pristas R, Dixon D, et al. The incidence of
complex regional pain syndrome after fasciectomy for
Dupuytren’s contracture: a prospective observational study
of four anesthetic techniques. Anesth Analg . 2006;102(2):
499–503.
19. Au-Yong IT, Wildin CJ, Dias JJ, Page RE. A review of com-
mon practice in Dupuytren surgery. Tech Hand Up Extrem
Surg . 2005;9(4):178–187.
20. Foucher G, Medina J, Navarro R. Percutaneous needle
aponeurectomy: complications and results. J Hand Surg Br .
2003;28(5):427–431.
21. Rodrigo JJ, Niebauer JJ, Brown RL, et al. Treatment of
Dupuytren’s contracture: long-term results after fascioto-
my and fascial excision. J Bone Joint Surg Am . 1976;58:
380–387.
22. Sinha R, Cresswell TR, Mason R, Chakrabarti I. Function-
al benefi t of Dupuytren’s surgery. J Hand Surg Br . 2002;
27(4):378–381.

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c h a p t e r
Rehabilitation of the Injured Hand
Michele A. Leadbetter, OTL, CHT / James P. Higgins, MD
INTRODUCTION TO HAND THERAPY
Hand injuries can be physically and emotionally challeng-
ing and require a highly skilled level of supervision and
guidance. Therapists provide a critical link between the
patient and the surgeon, mitigate potential problems, and
serve as patient advocates and educators. Hand therapists
help promote the best surgical outcome by restoring func-
tion and reducing disability. The fi eld of hand therapy con-
tinues to evolve as hand surgery techniques improve and
our understanding of the mechanics and biology of tissue
healing expands.
Hand therapy is a specialized form of rehabilitation that
is carried out by a licensed physical or occupational thera-
pist trained in the treatment of injures to the hand and
upper extremity. Certifi ed hand therapists (CHTs) have
studied and demonstrated profi ciency in rehabilitation of
the hand in order to become nationally certifi ed. Eligibility
for the certifi cation examination requires at least 5 years
of experience and 4000 hours of practice in hand and
upper extremity rehabilitation. Certifi ed hand therapists
are required to continue their education and competencies
not only in the area of physical therapy and occupational
therapy but also in current treatment and research specifi c
to hand rehabilitation.
EVALUATION/SYSTEMS REVIEW
Upon fi rst meeting the patient, CHTs perform a com-
prehensive evaluation and systems review to establish a
baseline and develop an individualized plan of care. The
evaluation addresses the patient’s physical, psychological,
and psychosocial factors.
Objective measurements and tests are completed the
fi rst day, respecting any surgical precautions or contraindi-
cations for specifi c injuries. Not all tests and measurements
are appropriate or necessary upon the initial evaluation
and prioritization is imperative.
CHTs also take note of the patient’s posturing, the pas-
sive attitude of the hand, how the patient holds and uses
their hand, the color and condition of the skin and nails,
how the patient talks about their hand injury and rates
pain, as well as their willingness to participate in treat-
ment. Physical, mental, and cognitive comorbidities are
also documented. These observations provide valuable
information for developing a treatment plan.
Components of the initial evaluation:
1. Active, passive, active assisted range of motion
(AROM, PROM, AAROM): Degrees and quality of
joint motion are recorded, reasons for limitations are
documented (ie, intrinsic, extrinsic, capsular tight-
ness, scar adhesions) ( Figure 59-1 ).
2. Strength testing: Grip and pinch measurements,
manual muscle testing
3. Sensory
evaluation:
two-point
discrimination,
Semmes-Weinstein monofi laments and functional
sensory testing (eg: stereognosis, hot/cold, sharp/dull).
Electrical nerve studies are completed in some clinics
according to physician’s orders.
4. Edema measurements: circumferential and volu-
metric
5. Wound assessment: stage of healing, size, exudate,
color, odor, etc
6. Standardized tests for coordination and dexterity
7. Functional capacity evaluation
In addition to the therapy evaluation fi ndings, it is very
important for the surgeon to provide as much informa-
tion as possible regarding the patient’s injury and proce-
dure performed. Factors that will affect the evaluation and
treatment plan are:
1. Mechanism of injury and the time elapsed from the
injury/surgery
59

702 • CHAPTER 59
2. Structures repaired or compromised (ie, pulleys, ten-
don, digital nerves)
3. Procedure performed, including:
a. Type, strength, and quality of repair
b. Method of fi xation/stability of fracture
c. Tension on the repair
d. Tissue quality/abnormalities
4. Tissue viability/vascular status
These factors can signifi cantly affect the treatment
plan and pace. These factors infl uence the type and posi-
tion of splints, how much protection is needed, how and
when to progress ROM and strengthening, and the rate of
improvement expected. The surgeon should communicate
any specifi c precautions or concerns that are identifi ed
during the procedure, as well as their own expectations
of the outcome. This information, combined with evalua-
tion fi ndings, will assist the therapist in balancing between
protecting the stability of the injury and surgery while pro-
moting mobility for function.
REHABILITATION OF COMMON
INJURIES: FLEXOR TENDONS
Flexor tendon injuries are one of the most common inju-
ries to the hand. These injuries present a challenge to
surgeon and therapist and require a signifi cant amount
of therapy for the patient. Due to the biomechanics of
the digital fl exors and the tendon excursion necessary for
making a fi st, it is important to encourage both tendon
gliding for function as well as protection of the repaired
tendon. Following surgery, the goal of therapy is to pro-
mote function and avoid a loss of motion due to rupture
or alternatively excessive stiffness and scaring. It is for
these reasons that a signifi cant amount of research has
been completed to improve surgical technique and post-
operative care.
FIGURE 59-1. Tools: digital goniometer.
Since the mid 1970s, much research has been done
to refi ne procedures for primary fl exor tendon repairs.
Through this research it has been demonstrated that ten-
dons heal with increased strength and improved excursion
if subjected to early mobilization. The application of con-
trolled stress (ie, motion) has been proven to increase the
tensile strength, the collagen organization, and intrinsic
healing through synovial exchange. The result is decreased
adhesion formation, and a reduced chance of gap formation
or rupture at the repair site. Research has also shown that
early active mobilization provides greater tendon glide
than passive range of motion exercises. 1
While advances in fl exor tendon surgery and reha-
bilitation have improved outcomes in all zones of fl exor
musculotendinous injuries, protocols have been evolv-
ing with a focus on improvement of injuries in the hand
(zones I–V), with particular interest in the most chal-
lenging injuries within zone II (the digital fl exor tendon
sheath) ( Figure 59-2 ).
Traditional immobilization protocols and early PROM
protocols such as the Kleinert-Lister Rubber Band Traction,
the Modifi ed Kleinert, and the Duran-Houser have largely
been replaced with immediate-controlled mobilization
protocols. Immobilization for 3 to 4 weeks is no longer the
common treatment technique, unless medically indicated.
FIGURE 59-2. Flexor tendon zones.

REHABILITATION OF THE INJURED HAND • 703
Mobilizing tendons using an early controlled active motion
program has now become the standard of care. Exceptions
may be made for comorbidities, age, comprehension, or
cognitive status.
Early active motion protocols (EAMPs) are largely
based on the physiologic phases of wound healing and
collagen proliferation. Immobilizing tendon repairs for
3 weeks (into the fi broblastic stage) allows for increased
fi broblast and collagen proliferation, and contributes to
the formation of adhesions between the tendon and sur-
rounding soft tissue. Initiating early active mobilization at
postoperative days 0 to 5 (during the infl ammatory phase)
has been shown to be the most effective method for lim-
iting adhesions, decreasing work of fl exion, and returning
the strength and excursion to the repaired tendon. 1 , 2
The therapist’s ability and confi dence using early
motion protocols is directly related to improved surgical
design, technique, increased number of strands, and type of
suture performed. These repairs allow for immediate con-
trolled motion with active “place and hold” exercises and
light active contractions within a safe range. 3 According
to Strickland, the most favorable outcomes are achieved
with a strong suture technique and immediate controlled
motion. 1
Other factors that may infl uence adhesions and drag on
repaired tendons are:
1. Trauma to tendon sheath from injury and/or surgery
2. Tendon ischemia
3. Tendon immobilization
4. Fractures, edema, and wounds
5. Gap formation
6. Tendon sheath/pulley compromise
Different protocols have been created by various centers
around the world. Although several specifi c EAMPs have
been described, all EAMPs share the following features:
• Minimum of a four-strand, core suture tendon repair
• Initiation of ROM within the fi rst 3 to 5 days
postoperatively 4
• Edema management and PROM preceding AROM to
maintain supple joints
• Cautious limitation of the strength of active muscle
contraction
• Reliance on patient compliance and motivation
With most protocols, the dorsal blocking splint is dis-
charged by week 6 and gradual resistive exercises are
permitted at week 8. The differences that exist between
proposed EAMPs include:
• Splint position (eg, wrist from 30 degrees of fl exion
to 30 degrees of extension)
• Using multiple splints, rubber band traction versus
straps
• Frequency, duration, repetitions, and progression of
AROM exercises ( Figure 59-3 )
Injuries to zones V–VIII may be treated differently
based on other additional structures (artery, nerve, wrist
fl exor muscles), the propensity for adhesion formation, the
proximity to the tendon muscle junction, and muscle belly
injury. Table 59-1 provides examples of some commonly
used EAMPs.
One additional EAMP worth mentioning is the
Pyramid of Progressive Force Application, described
by Groth. 8 This protocol differs from those previously
mentioned by timing the motion exercises based on an
individual’s biological healing process and speed of their
progress. Exercises are progressed based on comparing
PROM to AROM during each visit; the less responsive a
patient’s soft tissue, the faster the program is progressed
( Figure 59-4 ). This protocol does not offer splinting or
time parameters.
FIGURE 59-3. (A) PROM in dorsal blocking splint and (B) place and hold AROM.
A
B

704 • CHAPTER 59
FLEXOR POLLICIS LONGUS
REHABILITATION
The management of lacerations to the fl exor pollicis longus
(FPL) may be more diffi cult due to tension from tendon
retraction being greater with the FPL than for digital fl exor
lacerations. Flexor pollicis longus lacerations are most often
treated with early PROM or dynamic fl exion, and AROM
may wait until the 3 weeks postoperative due to less adhe-
sion formation and increased rupture rates. Early AROM
TABLE 59-1. Some Commonly Used EAMPs for Flexor Tendon Zones I–V
Author
Splint Position
Early AROM
Progression
The Curtis National
Hand Center
(Formby ME. 2004) 2
Dorsal blocking splint
Wrist: neutral
MCPs: Flexion 60°–70°
IPs: Full extension
Day 0-5: Hourly
1. PROM to prime joints,
10–15 reps
2. Place/hold and AROM
1–3 x to 50% of full
PROM arc
3. Increase arc of
place/hold as PROM
improves
1. Week 3: Increase
AROM to full
2. Week 4: Unassisted
AROM
3. Modify active
reps and sessions
depending on AROM
progress
The Indiana Hand
Center (Cannon and
Strickland, 2001) 5
• Uses 2 splints
• Static DBS and
hinged
• Hinged splint used
for active tenodesis
exercises, weeks 1-4
Dorsal blocking splint
Static splint:
Wrist: 20°–30° fl exion
MCPs: 50° fl exion
IPs: Full extension
Hinged splint: Allows full wrist
fl exion to extension 30°
MCPs: 60°, IPs: 0
Day 3: Hourly PROM
fl exion 15 reps
In hinged splint: Hourly
25 reps:
1. PROM digits with wrist
extended 30°
2. Gentle active hold
fl exion 5 seconds
3. Flex wrist and release
active fi st
1. Week 4: Hinged
splint discharged
and unrestricted
tenodesis exercised
are permitted
2. Week 6: Composite
extension begins
Short arc motion
(Evans and
Thompson, 1997) 3,6
• Zones I and II
• Limited to repairs
with a modifi ed
Kessler and
epitendinous suture
Dorsal blocking splint
Wrist 30°–40° fl exion
MCPs: 30°–45° fl exion
IPs: Full extension
Zone I: DIP extension block
splint 40°–45° fl exion
Zone II: Dynamic fl exion bands
with palmar pulley
Night: Disconnect dynamic
tension bands. IP joints are
strapped in full extension
Day 1–3
1. 10–20 reps of PROM
to distal palmar crease
2. 10–20 reps of AROM
IP extension while
holding the MCP
fl exion with opposite
hand
3. 1–3 days postop. Only
in therapy, short arc
place and hold. Use
pinch meter to measure
active force. Passive
tenodesis exercise
1. Week 3: patient
permitted to perform
place/hold exercises
at home.
D/C DIP splint for
Zone I repair
2. Progress therapy
as per other fl exor
tendon protocols
Early AROM and
dynamic splinting
(Silfverskiold and
May, 1995) 7
• Uses dynamic
tension during
the day
Dorsal blocking splint
Day: Wrist 30°–40° fl exion
MCPs: Flexion 50°–70°
Dynamic fl exion with palmar
pulley
Splint ends at IP joints
Night: Disconnect dynamic
tension bands. IP joints
strapped in full extension
Hourly, 10 reps
1. Active extension while
manually unloading
dynamic tension. Then
allow dynamic tension
to fl ex digits.
2. When in full passive
fl exion, gently
contract muscle to
hold 2–3 seconds
Week 4: Remove splint
for unassisted AROM
exercises at home
DBS, dorsal blocking splint; AROM, active range of motion; MCP, metacarpophalangeal; IP, interphalangeal; DIP, distal interphalangeal; PROM,
passive range of motion; D/C, discharge.
for FPL lacerations can be used, yet it has not been shown
to signifi cantly improve outcomes. 3 , 9
With all tendon rehabilitation, both with early active
and immobilization protocols, complications may include
adhesion formation, joint contracture, tendon rupture,
pulley failure, and tenosynovitis. With associated digital
nerve injuries, there are also the possible complications
of sympathetic fl ares and hypersensitivity which can limit
functional use of the hand postoperatively.

REHABILITATION OF THE INJURED HAND • 705
EXTENSOR TENDONS
The management of extensor tendons presents its own
unique challenges because of the complex and intricate
anatomy of the extensor tendon system.
The extensor mechanism is a dynamic system involving
extrinsic muscles, intrinsic muscles, and their soft tissue
connections. Even a minor injury to part of this system
can decrease function and alter the mechanics of normal
motion.
Treatment for extensor tendon injuries is based on the
location, or zone, and severity of the laceration. The level
of protection, the splint position, and the ROM permit-
ted have been established from studies measuring the
effects that joint position has on tendon gliding. 10 Static
splinting generally remains the standard of care for simple
extensor tendon injures in zones V–VIII; however, with
increased complexity of injuries, patients can benefi t
from the use of early motion protocols ( Figure 59-5 ). 11
As with primary fl exor tendon repairs, early motion pro-
tocols for extensor tendon rehabilitation are designed to
promote tendon excursion by applying controlled force
without compromising the repair. The progression and
design of these protocols is based on studies of extensor
tendon excursion as it relates to the degree of ROM at
individual joints. 10 - 12 The use of early AROM protocols
is dependent on the strength and quality of the repair as
well as the level of trauma to the surrounding tissues.
Early motion protocols ( Table 59-2 ) for extensor ten-
dons must be initiated within the fi rst 24 to 48 hours
postoperatively with a compliant patient and guided by
FIGURE 59-4. Progressive force exercises to the intrasynovial fl exor tendon injury
and repair.8
Wrist protected
Passive protected extension
Place and hold
Active composite fist
Hook and straight fist
Isolated joint motion
Discontinuation of proctective splint
Resistive composite fist
Resistive hook & straight fist
Resistive
isolated
joint motion
Wrist protected
Wrist unprotected
Pyramid of progressive force application
FIGURE 59-5. Extensor tendon zones.

706 • CHAPTER 59
TABLE 59-2. Commonly Used Protocols for Extensor Tendon Zones I–VII
Zone
Splint
Timing Progress
Complications
Zone I and II
“Mallet fi nger”
Terminal tendon rupture,
avulsion fracture
DIP immobilization 6–8 wk
in full extension
All proximal joints
mobilized
Slow mobilization of the
DIP AROM at 6–81
wk.
No early AROM indicated
May require fi xation
Monitor DIP lag
Maceration
Night splinting 3–6 mo
Zone III and IV
Boutonnière
Central slip laceration,
rupture, avulsion
fracture
PIP extension splint or
cast 6 wk,
DIP AROM
Short arc motion protocol:
template splint used to
allow limited AROM 10
Slow mobilization of PIP
AROM at 6–81 wk.
Monitor PIP joint lag for
boutonnière
Adhesions
Night splinting 3–6 mo
Zone III and IV
Central slip with lateral
band involvement
PIP and DIP extension
splint, 6–8 wk in full
extension
Slow mobilization of
isolated PIP and DIP
ROM at 6 wk
Monitor PIP lag for
boutonnière
Adhesions
Night splinting 3–6 mo
Zone V and VI
Dorsal hood
Sagittal bands
Juncturae tendinum
Hand based or forearm
based
Wrist: 30° extension MCP:
extension
IPs: free
AROM 3–4 wk, splint
6 wk
MCP deviation
MCP extension lag
Adhesions
Zone VI and VII
Wrist: 30° extension MCP:
extension
IPs: free
Dynamic MCP extension
splint, allow MCP
fl exion to 40°
AROM 3–4 wk, splint
for 6 wk.
Limited fl exion, assisted
extension in dynamic
splint until 4 wk
Adhesions very common
Extrinsic tightness
Zone VII1
Tendon muscle junction
and muscle belly
Wrist: 30° extension
possibly long arm splint
at 90°
AROM 3–4 wk, splint
for 6 wk.
Adhesions very common
Extrinsic tightness
DIP, distal interphalangeal; PIP, proximal interphalangeal; AROM, active range of motion; MCP, metacarpophalangeal; IP, interphalangeal.
an experienced hand therapist. Other protocols have been
developed using dynamic rubber band traction to allow
early tendon glide within a short arc of motion. 12
Common features of all extensor tendon programs
are: any extension lag must be monitored closely and the
therapist must adjust the motion and splinting program
accordingly, the protective splint is used for 4 to 6 weeks,
and occasionally for zone V1, a night interphalangeal (IP)
extension splint may be indicated to avoid proximal inter-
phalangeal (PIP) joint contractures. As with fl exor tendons,
extensor tendon protocols differ in splint position, active
and passive ROM, and timing.
Tendon lacerations to the extensor pollicis longus in
zones TI are treated similarly to the digits, with IP exten-
sion splinting for 6 to 8 weeks. Lacerations in zone TII are
splinted in a hand-based splint with metacarpophalan-
geal (MCP) and IP joints in extension and in full radial
abduction. Lacerations in zones TIII and TIV should be
splinted with the wrist at 20 to 30 degrees extension and
thumb in maximum end range extension and abduction
(as compared with unaffected hand). By week 3, AROM
to all joints is progressed and by week 6 the splint is dis-
charged. Dynamic protocols can be used and splinting
allows passive fl exion of the IP joint, with assisted exten-
sion ( Figure 59-6 ). 11 , 12
TENDON TRANSFERS AND
FREE MUSCLE TRANSFERS
The body of research for these procedures is small as it
relates to hand therapy; however, what has been shown is
that given the strength of the weave, early controlled motion
can be tolerated and provides improved results with less
stiffness and adhesions. According to Brand and Strickland,
stiffness and adhesions are the most common cause of dis-
appointment with tendon transfers. Early motion can be
benefi cial considering the condition of the soft tissue enve-
lope. 7 , 13 – 15 Early motion programs have been described in
the literature by various authors for different transfers.
Given suitable suture technique, early mobilization of
the transfer has been shown to be effective in improving
ROM, decreasing adhesions, hastening the motor learning
process, and decreasing the time in therapy. 15 – 17
The therapist plays an integral part in the preoperative
process and can be helpful in preparing the patient for sur-
gery. Preoperative treatment is necessary to resolve joint

REHABILITATION OF THE INJURED HAND • 707
FIGURE 59-6. Dynamic extension splint for complex
extensor tendon laceration to allow early motion for tendon
gliding.
contracture, maintain joint PROM, strengthen and educate
possible donor muscles, and improve soft tissue mobility
by minimizing scar tissue and edema. Therapists can also
help outline the postoperative plan and assist in setting
realistic goals and expectations. If possible, the therapist
should observe the surgery to gain a better understanding
of the procedure.
Early PROM and/or AROM can be initiated postopera-
tively between weeks 1 to 3 depending on the surgeon’s
preference, technique, and the soft tissue status of the trans-
fer route. Typically at week 3 to 4, short but frequent AROM
exercise sessions and functional activities are initiated. 16
Biofeedback and electrical stimulation may be benefi cial
especially when patients are having diffi culty activating the
transfer. The splint may be discharged by 6 weeks, and at
this time any extrinsic or transfer tightness can be addressed
with splinting and stretches and very light resistance can
begin. As with primary repairs, resistive exercises can be ini-
tiated at 8 weeks postoperatively, with the goal to return to
work and avocational activities by weeks 10 to 12.
NERVE INJURY AND REPAIR
Hand therapists can be especially valuable following nerve
injury and can assist patients in regaining function and
minimizing complications. Supervised therapy is aimed at
preventing joint stiffness, scar hypersensitivity, allodynia,
and chronic regional pain syndrome.
Postoperative treatment is benefi cial for many reasons.
Often patients will require splinting to protect a nerve
repair. The level of tension on a nerve repair postopera-
tively will determine the position of the splint and level
of protection it provides. Splinting may also be indicated
to promote function and prevent joint contracture while
waiting for muscle reinnervation ( Figures 59-7 , 59-8 , and
59-9 ). These splints can often be comfortable and low
profi le to minimize disruption to the patient’s daily life.
Patients may need these splints for weeks to months fol-
lowing a nerve injury.
As a nerve regenerates, therapy is focused on desensi-
tization, functional sensory reeducation, nerve mobiliza-
tion, strengthening, ROM, and neuromuscular retraining.
Desensitization is a progressive process by which sensory
FIGURE 59-7. Ulnar nerve anticlaw splint.
input is introduced to the patient slowly and systemati-
cally. As the patient’s sensation improves and the pain-
ful response to touch diminishes, the noxious stimulus
is increased until normal functional sensory awareness
is achieved. Sensory reeducation is the next phase and
requires a higher level of sensory awareness. It focuses on
reeducating the sensory receptors for function, including
moving and static touch discrimination, point localiza-
tion, and object recognition.
Adhesive neuritis may develop from closed traction
injuries, open lacerations, or surgical nerve repair/manipu-
lation. Patients may present with signifi cant pain and par-
esthesias, and may have developed stiffness from avoiding
painful motion. Nerve mobilization, or gliding, is a com-
monly used treatment technique that therapists may use
to decrease pain and increase function. Treatment with
FIGURE 59-8. Medial nerve C-bar to prevent fi rst web
space contracture.

708 • CHAPTER 59
FIGURE 59-9. Radial nerve palsy splints (low profi le and
with outrigger).
A
B
segmental and full length nerve gliding has been shown
to be effective in decreasing pain caused by adhesions
and infl ammation around an injured nerve.
SOFT TISSUE MANAGEMENT:
EDEMA AND SCAR
Edema management can be initiated immediately postsur-
gically and can be effective continuing into the remodeling
phase of healing. There are many different techniques used
to decrease edema and the selection of which method to
use will depend on the stage of healing and tissue qual-
ity. Edema management can be as basic as elevation and
active pumping or as complicated as manual lymphatic
drainage and wrapping. Examples of treatment interven-
tions include:
• Elevation
• AROM (active muscle pumping)
• Massage and manual lymphatic drainage
• Wrapping (Coban, lymphatic wrapping, string)
• Compression garments (sleeves, gloves, custom or
“off the shelf”)
• Modalities (ice, electrical stimulation such as
high-volt, contrast baths)
Scar management is another critical component of hand
therapy. It can be very important for increasing joint and
tissue mobility, decreasing adhesions for increased ROM,
and decreasing hypersensitivity for improved function.
Scar management can also be helpful in restoring and
improving the appearance of the injured hand. Through
improved cosmesis, patient’s may have increased ease of
integrating the injured hand back into daily activities.
Studies have demonstrated that pressure and tension on
the tissue will decrease the proliferation of collagen forma-
tion thus decreasing scar. 18 Examples of treatment interven-
tion for scar management are listed below ( Figure 59-10 ).
• Silicone gel (sleeves and pads)
• Elastomer molds ( Figure 59-11 )
• Tape
• Compression garments
• Dycem for scar massage/retraction
• Massage tools (vibration and suction)
• ROM
• Casts and splints
FRACTURE MANAGEMENT:
HAND AND WRIST
Treatment for patients with fractures about the hand and
wrist may vary depending on many factors: the type and
location of the fracture, the stability of the fracture or
fi xation, the mechanism of injury, associated injuries, the
patient’s age and comorbidities ( Table 59-3 ).
FIGURE 59-10. Scar management products (left to
right): massage tools, tape, iontophoresis, scar molds gel
pads, Dycem, Coban, gel, and compression sleeves.

REHABILITATION OF THE INJURED HAND • 709
FIGURE 59-11. Elastomer mold for keloid scar before (A) and after application (B).
A
B
TABLE 59-3. Treatment for Fractures
Fracture
ROM and Treatment
Splint
Complications
Distal radius
ORIF
AROM all unaffected joints
(proximal and distal)
A/AAROM wrist as allowed
Edema management
Scar mobilization
At 2–4 wk:
Wrist cock-up splint
Munster splint or sugar
tong to limit rotation
with TFC or DRUJ
involvement
FPL adhesions (volar
plating)
Extensor adhesions
(dorsal plating)
CTS
Distal radius
Nonoperative, cast
AROM all unaffected joints
(proximal and distal)
Edema management to
digits
At 4–6 wk:
Wrist cock-up splint
Munster splint or sugar
tong
Digital stiffness
Persistent edema
Extrinsic tightness
CTS
Distal radius
Ex-fi x, or percutaneous
pinning
AROM all unaffected joints
(proximal and distal)
Edema and scar
management
Pin care
Protective splinting over
ex-fi x
Wrist splint after
hardware removal
Extrinsic tightness
Radial sensory nerve
irritation
CTS
Pin site infection
Metacarpal
With or without
ORIF
Percutaneous pinning
ROM PIP/DIP joints
ROM MCP and wrist as
allowed
Edema management
Scar mobilization
Extensor tendon gliding
Wrist or hand based
ulnar or radial gutter
MCPs in fl exion
IP joints in extension
EDC adhesions
MCP joint extension
contractures
PIP joint fl exion
contractures
Phalanx: proximal and
middle
With or without
ORIF
Percutaneous pinning
ROM MCP, PIP, DIP joints
as allowed
Edema management
Scar mobilization
Digital extension splint
or gutter with MCPs in
fl exion
IP joints in extension
IP joint: 30° fl exion with
volar plate injury
MCP joint extension
contractures
PIP joint fl exion
contractures/extension
lag
Flexor adhesions
Tuft/distal phalanx
With or without
percutaneous
pinning 19 , 20
A/PROM proximal joints
Edema management
Desensitization
Tip protector or stack
splint with DIP in
extension
Hypersensitivity at tip
or nail bed
ORIF, open reduction and internal fi xation; AROM, active range of motion; AAROM, active assisted range of motion; ROM, range of motion; PIP,
proximal interphalangeal; DIP, distal interphalangeal; MCP, metacarpophalangeal; TFC, triangular fi brocartilage complex; DRUJ, distal radioulnar
joint; IP, interphalangeal; FPL, fl exor pollicus longus; CTS, carpal tunnel syndrome; EDC, extensor digitorum communis.

710 • CHAPTER 59
REFERENCES
1. Strickland JW. Development of fl exor tendon surgery:
twenty-fi ve years of progress. J Hand Surg. 2000;25A:
214–235.
2. Formby ME. Flexor tendon repair. In: Burke SL, Higgins JP,
McClinton MA, Saunders RJ, Valdata L, eds. Hand and Up-
per Extremity Rehabilitation: A Practical Guide. 3rd ed. St.
Louis, MO: Elsevier; 2004:227–244.
3. Evans RB. Early active motion after fl exor tendon repair. In:
Berger R, Weiss A, eds. Hand Surgery. Philadelphia: Lippin-
cott Williams & Wilkins; 2010:709–735.
4. Halikis MN, Manske PR, Kubota H, Aoki M. Effect of im-
mobilization, immediate mobilization, and delayed mobi-
lization on the resistance to digital fl exion using a tendon
injury model. J Hand Surg Am. 1997;22:464–472.
5. Cannon N, Strickland J. Diagnosis and Treatment Manual for
Physicians and Therapists . 4th ed. Indianapolis, IN: The Hand
Rehabilitation Center of Indiana; 2001.
6. Evans RB, Thompson D. Immediate active short arc of motion
following tendon repair. In: Hunter J, Schneider L, Mackin
E, eds. Tendon and Nerve Surgery in the Hand. St. Louis, MO:
Mosby; 1997:362–391.
7. Silfverskiold KL, May EJ. Early active mobilization after
tendon transfers using mesh reinforced suture techniques.
J Hand Surg Br. 1995;20:291–300.
8. Groth GN. Pyramid of progressive force exercises to the in-
jured fl exor tendon. J Hand Ther. 2004;17:31–42.
9. Elliot D, Moiemen NS, Flemming AF, Harris SB, Foster AJ.
The rupture rate of acute fl exor tendon repairs mobilized
by the controlled active motion regimen. J Hand Surg Br.
1994;19:607–612.
10. Evans RB, Burkhalter WE. A study of the dynamic anatomy
of extensor tendons and implications for treatment. J Hand
Surg Am. 1986;11:774–779.
11. Saunders RJ. Management of extensor tendon repairs. In:
Burke SL, Higgins JP, McClinton MA, Saunders RJ, Valdata
L, eds. Hand and Upper Extremity Rehabilitation: A Practical
Guide. 3rd ed. St. Louis, MO: Elsevier; 2006:271–292.
12. Carney KL, Griffen-Reed N. Rehabilitation of extensor
tendon injury and repair. In: Berger R, Weiss A, eds. Hand
Surgery. Philadelphia: Lippincott Williams & Wilkins; 2004:
787–778.
13. Trumble TE. Tendon transfers. In: Trumble TE, ed. Principles
of Hand Surgery and Therapy. St. Louis, MO: Saunders; 2004:
343–360.
14. Brand PW. Mechanics of tendon transfers. In: Hunter JM,
Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand and
Upper Extremity. 5th ed. St. Louis, MO: Mosby; 2002.
15. Germann G, Wagner H, Blome-Eberwein S, Karle B,
Wittemann M. Early dynamic motion versus postoperative
immobilization in patients with extensor indicis proprius
transfer to restore thumb extension: a prospective random-
ized study. J Hand Surg Am. 2001;26:1111–1115.
Regardless of surgical intervention, for all patients
with distal radius fractures, common complications
can include: median nerve symptoms/carpal tunnel
syndrome, extrinsic tightness, distal radioulnar joint
instability or triangular fi brocartilage complex inju-
ries, chronic edema and stiffness, and chronic regional
pain syndrome. With phalanx and metacarpal fractures,
FIGURE 59-12. Splint to resolve intrinsic tightness and
interphalangeal joint stiffness.
common complications can include signifi cant joint stiff-
ness, MCP/PIP extension and fl exion contractures, PIP
extension lag, intrinsic tightness from splint position
and edema, extrinsic tightness or adhesions (fl exor and
extensor), scar, and hypersensitivity particularly when
crush injuries occur.
Hand therapists can be helpful in identifying and treat-
ing these problems and are particularly critical in prevent-
ing stiffness. Using various modalities, ROM, stretching,
and scar mobilization techniques, therapy can be benefi -
cial in improving joint and tissue mobility. Patients may
also have their protective splints remolded to provide
increased stretch or the therapist may choose to fabricate
or order a dynamic or static progressive splint to provide
low load stretching for tissue elongation. Figure 59-12
shows an example of a static progressive splint to increase
digital ROM.
SUMMARY
Hand therapy has evolved to become a critical component
in the treatment of injuries to the hand. Protocols con-
tinue to evolve as the understanding of the mechanics and
biology of wound healing improves. Communication and
coordination of care between the surgeon and therapist is
the keystone to enabling hand surgery patients to achieve
more rapid and complete return of function.

REHABILITATION OF THE INJURED HAND • 711
16. Rath S. Immediate active mobilization versus immobiliza-
tion for opposition tendon transfer in the hand. J Hand Surg
Am. 2006;31:754–759.
17. Kozin SH. Tendon transfers for radial and median nerve
palsies. J Hand Ther. 2005;18:208–215.
18. Evans R, McAcliffe JA. Wound management. In: Hunter
JM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand
and Upper Extremity. 5th ed. St. Louis, MO: Mosby; 2002:
311–327.
19. Freeland AE, Torres JE. Extraarticular fractures of the pha-
langes. In: Berger R, Weiss A, eds. Hand Surgery. Philadel-
phia: Lippincott Williams & Wilkins; 2004:123–137.
20. Duncan SFM, Weiland AJ. Extraarticular distal radius frac-
tures. In: Berger R, Weiss A, eds. Hand Surgery. Philadelphia:
Lippincott Williams & Wilkins; 2004:247–275.

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The reconstruction of chest wall defects is based on the
tissues lost and their respective function. Any repair must
consider the underlying thoracic organs as well as the skel-
etal support and soft tissue coverage. Chest wall defects
may be divided into congenital and acquired problems.
Most congenital problems are usually nonfunctional and
are of concern primarily from an aesthetic point of view.
Acquired problems most often follow open-heart surgi-
cal procedures, but may also be due to tumor extirpation
and trauma. Post cardiac surgery chest reconstruction has
evolved into a discipline of its own as not only the sternal
deformity must be considered but the co-morbidities of
infection, chronic obstructive pulmonary disease, diabetes
and the underlying cardiovascular disease. Trauma to the
chest often results in rib injuries and only in severe direct
trauma, is the sternum ever involved. The ribs and sternum
are well vascularized and unless there is severe displace-
ment that requires re-positioning and fi xation, healing is
generally spontaneous.
Chest wall reconstruction dates back to the eighteenth
century when Aimar performed the fi rst recorded resec-
tion of osteosarcoma of the ribs in 1778. Airway control
with endotracheal tubes and positive pressure ventilation,
as well as closed suction systems, were introduced in the
late 19th century and thus paved the way for the fi eld of
thoracic surgery. A subsequent report in 1898 described
resection of a bony chest wall tumor, in which three ribs
were included in the specimen.1 In 1913, Lund performed
resection of a sarcoma involving several components of the
chest wall.2
In 1957, Julian introduced the median sternotomy to
gain access to the thoracic cavity.3 The initial infection
rates were high with mortality rates of 70%. Early man-
agement consisted of open treatment with granulation
and healing by secondary intention. In 1963, Shumaker
and Mandelbaum used surgical debridement followed by
closed suction irrigation of the sternum. This decreased
but did not eradicate the associated mortality.4 In 1976,
Lee improved on this concept of debridement with the
addition of transposed omentum in order to bring healthy,
vascularized tissue to the mediastinal wound bed.5 In 1979,
P.G. Arnold expanded upon this idea to use muscle fl aps,
primarily the pectoralis major to promote wound healing.6
The use of vacuum assisted closure (VAC) therapy in the
1990’s for sternal wounds provided a bridge to surgery by
improving granulation, reducing bacterial counts, shrinking
wound sizes and in some cases resulting in eventual com-
plete healing.7 In 2006, the Lenox Hill experience with
over 14,000 total cardiac patients over a 17-year period
was published. The rate of sternal wound infection in this
series was 2.3% refl ecting present day improvement in tho-
racic surgery. Of the 336 patients who required secondary
closure, the 30-day mortality was 3%, with a morbidity
rate of 5%. Either secondary exploration or VAC therapy
was required to facilitate complete healing.8
The most common congenital anomalies seen are pec-
tus excavatum, pectus carinatum, and Poland syndrome. A
few of these deformities may require early intervention as
they may lead to severe functional problems during growth
and development. Pectus excavatum, a caved-in or funnel
Reconstruction of the Chest –
Congenital and Acquired Anomalies
and Defects
Norman H. Schulman, MD, FACS / Tara Lynn Huston, MD
60
c h a p t e r

714 • CHAPTER 60
shaped chest is the most common congenital chest wall
abnormality, which accounts for 90% of the patients with
congenital chest wall defects. It occurs in approximately
1 in 300-400 births, with a 3:1 male to female predomi-
nance. Even though the etiology is not known, it is thought
to be genetic as there is a family history in over one third
of the newly diagnosed cases.9 In its most severe form, it
can cause disruption of the placement of the mediastinal
structures including the heart, great vessels and bronchi.
Pectus excavatum was initially treated using the invasive
Ravitch procedure, introduced in 1949, which consisted of
sternal detachment and cartilage resection. A small, tem-
porary bar was then inserted underneath the sternum until
the cartilage grew back. More recently, the Nuss proce-
dure has been used which places concave steel bars into
the chest, below the sternum. The bar is then rotated to
a convex position to correct the deformity. Pectus carina-
tum, or “pigeon chest,” is the second most common defect
occurring in 5-7% of patients, also more common in males.
It rarely requires surgical correction.
Poland syndrome, which consists of the absence of the
sternal head of the pectoralis and ipsilateral cutaneous syn-
dactyly, occurs in 1 in 7,000-100,000 live births.10 It affects
males more commonly (3:1) and occurs on the right side
of the body twice more commonly than the left. It has
been associated with other syndromes, including Möbius
syndrome, which is a congenital bilateral facial paraly-
sis and inability to abduct the eyes. Other less common
inborn disorders involving defects of the chest wall include
cleft sternum, pentalogy of Cantrell, asphyxiating thoracic
dystrophy, and spondylothoracic dysplasia.11
PATIENT EVALUATION
A treatment plan is developed during the initial consulta-
tion with the plastic surgeon. A detailed history is obtained
which includes several key pieces of information. The
patient’s gender, age, co-morbidities, medications, medical
and surgical history, including indications for the cardiac
procedure performed (if relevant) are obtained. The details
of any prior procedure such as pump time, valve insertion,
graft use, or any other prosthetic device or material needed
is also ascertained. The patient’s use of anti-coagulants is
important for timing of reconstruction, as is the current
respiratory status.
The initial physical examination should evaluate
the chest deformity or wound and any other physical
co-morbidities including general body habitus and men-
tal state. A gram-stain with culture and sensitivity of any
open or draining wound should be obtained. Antibiotics
will rarely cure these post-operative sternal infections but
are a vital adjuvant in the success of any attempt at sternal
wound reconstruction.
Prior to surgery, all pre-operative studies, scans and
medical records should be reviewed. A proper diagnosis
and classifi cation of the wound must be made. One algo-
rithm attempts to simplify the classifi cation and treatment
(Figure 60-1). Wounds are broken down into three distinct
Closed wound
Unstable stemum
Open wound for
drainage
and local care
Purulent drainage
Incision line
Sinus tracts
Chronic drainage
Staged OR
debridement
Wire removal
omental flap
Bilateral PM
myocutaneous flaps
Spontaneous
healing
Nonpurulent wound
Exposed bone and/or
wires
Intense local wound care
BID showers
QID dressings
VAC therapy
Debridement
Wire removal
Unipedicle PM muscle flap
Debridement
Wire removal
Bilateral pedicle PM
Latissimus, or
rectus flaps
Skin closure
Algorithm for reconstruction of sternal wounds
Reopen wound in OR
adjust remove or rewire
or apply titanium plates
Pedicled unilateral or
bilateral
PM muscle flaps
Subacute
Acute
Chronic
Purulence with
exposed grafts
FIGURE 60-1. Algorithm for reconstruction of sternal wounds.

RECONSTRUCTION OF THE CHEST – CONGENITAL AND ACQUIRED ANOMALIES AND DEFECTS • 715
categories. Acute wounds occur within the fi rst and second
weeks of surgery. They can present with open or dehisced
skin as well as with or without signs of infection. Sub-acute
wounds occur within 2-4 weeks of surgery and are gener-
ally marked by infection and purulence. Lastly, chronic
wounds occur anytime after the 4th or 5th week and usu-
ally present as single or multiple drainage tracts often with
positive cultures.8
A key part of the pre-operative evaluation is radiologic
imaging. Plain chest x-rays are the most important as they
provide a baseline condition of the lungs as well as the
number, position and condition of the primary fi xation
devices utilized, usually stainless steel wires, or less com-
monly titanium bars (or plates) and clasps. Computerized
tomography (CT) scans have only occasionally found to be
helpful, such as in the discovery of a rare pseudo-aneurysm.
The scans may prove useful if the clinical condition of
the patient is worse than that indicated by the condition
of the wound. In this instance, the CT scan may delin-
eate a deep collection, hidden on physical exam. Contrast
material should be avoided as it is not necessary and may
be dangerous for patients with pre-existing renal com-
promise. Spect-CT scans, which combines radio-isotope
scanning with computed tomography allows visualization
of an abscess or point of infl ammation only several mil-
limeters in size.
A team approach is vital to the success of the outcome
and must involve co-operation and communication with
the cardiothoracic surgery team. This must involve willing-
ness, availability and an ability for the plastic surgeon to
work with the cardiac surgeon to participate in all phases
of the treatment plan.
TREATMENT OF THE ACUTE POST
CARDIAC SURGERY WOUND
The history and physical should permit categorization of
the wound thereby suggesting treatment options. An acute
wound occurring within several days to within two weeks
FIGURE 60-2. Omental Inset to Mediastinum.
of the cardiac procedure must be regarded as a semi-emer-
gent condition requiring early or immediate intervention.
These wounds usually represent a dehiscence of the ster-
num with or without intact skin. Though infection may
not be present a large volume of sero-sanguineous fl uid in
the wound is typical. At greatest risk in a bypass procedure
would be exposed freshly placed bypass grafts. Exposure
of these grafts risks desiccation and failure therefore they
must be protected, kept moist and sealed as soon as pos-
sible with well-vascularized tissue.
Omental fl aps, delivered from the abdomen superfi cial
to the diaphragm provide well-vascularized tissue, which
can readily cover the grafts (Figure 60-2). Muscle fl aps
may be used but are not as fl exible for coverage and may
be better utilized in fi nal chest wall closure. General sur-
geons or plastic surgeons fully trained in general surgery
can readily harvest the omentum through an separate, ver-
tical epigastric incision or laparoscopically. With a history
of prior abdominal surgery, the open method is preferred
as the omentum may not be fully intact and either the
right or left segment may have to be obtained on its blood
supply. The right-sided blood supply is preferable, as it
provides for a fl ap with the longest reach, to the base of
the neck if necessary. Final chest closure is accomplished
by using two myocutaneous pectoralis fl aps and closing in
the midline over the mediastinum.12
If sternal rigidity is required, titanium fi xation bars
(SynthesR) that span the two edges of the sternum work
well (Figure 60-3).13 Sternal fi xation should not result in
tamponade, as closing pressures can be readily controlled
by the span of the bars. The bars can be used as bridges and
the muscle fl aps will not cause mediastinal compression
as they are detached on their under surface from the ribs
and sternum. In an urgent situation, where time and anes-
thesia are concerns, the skin can be brought together over
the omentum with deep dermal sutures without muscles.
To provide infection protection and which later may be
revised if necessary.
FIGURE 60-3. Titanium bars, screw and release pins.
Single layer muscle, dermis closure.

716 • CHAPTER 60
Sub-acute wounds are the most common. They occur
2–4 weeks after surgery and usually present as “sick”
patients with fevers, leukocytosis and purulent drainage.
Often these patients will have positive blood cultures. These
wounds are life threatening, but there is time to prepare
the wound properly for defi nitive therapy. Decompression
of the infected wound is performed as soon as possible,
either by opening the wound at the bedside under local
anesthesia or a more thorough procedure in the operating
room, which may include removal of sternal wires. Once
adequate drainage and decompression has been achieved,
the open wound is prepared for defi nitive closure. This
preparation involves multiple daily dressings of saline or
an ultra-dilute solution of povidone (1:100) to prevent
wound colonization. If tolerated, it is recommended that
the patients take twice daily showers. Once purulent fl uid
has been cleared, VAC therapy may be used until defi nitive
closure is offered, often a period of 2–7 days. VAC therapy
may close some of these wounds, but unless there has been
complete wire removal and thorough debridement in the
operating room, these wounds require secondary closure,
as they may become chronic.
The patient with the now “clean wound” is taken to the
operating room for defi nitive reconstruction. Prior to prep-
ping and draping the wound is re-cultured. Reconstruction
is begun by complete excision of all wound edges and wire
removal. Blood loss is controlled with the use of two cau-
terization devices, a Bovie and an argon beam coagulator.
Non-viable or infected portions of the sternum are debri-
ded at this time. In the sub-acute wounds, the mediasti-
num is often healed and adherent to the underside of the
sternum, therefore, extra care must be taken to avoid right
ventricular tears and absolute paralysis is a must during
this part of the procedure. Once debridement has been
completed the operative fi eld is copiously irrigated, usu-
ally with a pulsatile delivery of at least 2 liters of a broad-
spectrum antibiotic solution.14
Now a decision must be made for the best closure tech-
nique for the particular defect and the particular patient,
considering the clinical condition and co-morbidities. As
discussed in the opening of this chapter, the introduction of
muscle fl aps in mediastinal closure has been revolutionary,
resulting in a vast improvement in the survival from medi-
astinitis. The workhorse fl ap is the uni-pedicled pectoralis
major muscle fl ap. This muscle originates on the clavicle
and insets on the sternum, ribs and upper humerus. Its
main blood supply arises from the thorcoacromial artery
and vein, which should be left intact and never skeleton-
ized. The pedicle can be readily identifi ed arising from the
upper medial edge of the pectoralis minor during the dis-
section of the pectoralis major. If the uni-pedicled pectora-
lis major muscle is selected, the muscle can be inset from
the manubrium to just proximal to the xiphoid if properly
mobilized.
The dissection begins with the separation of the skin
and fat as a unit from the underlying muscle using cau-
tery dissection technique. The muscle is separated from
the sternum and ribs, the pedicle and its blood supply are
1
2
3
4
FIGURE 60-4. Unipedicle Pectoralis Major Inset. Drain
Arrows: 1. Subcutaneous, 2. Paramediastinal, 3. Muscle bed,
and 4. Axillary.
identifi ed and preserved. The distal end of the muscle is
encircled proximal to its humeral attachment, which is just
inferior to the cephalic vein. The humeral, sternal, and rib
attachments are divided as well as the medial one third of
its attachment to the clavicle to provide maximum mobil-
ity. The superior medial portion of the pectoralis major
may be back cut 3 or 4 cm to fi ll behind the manubrium
if necessary. Closure over the xiphoid can be obtained by
approximating the upper medial aspects of both rectus
abdominal muscles. Bilateral pectoral major muscles may
be used on their separate pedicles if a larger coverage area
is required.
The pectoralis muscle is inserted into the mediastinal
defect, usually a groove resulting from sternal wound
debridement and then suture fi xed on all sides. Four large
closed suction drains are placed: one in the axilla, one in
the muscle bed, one alongside the mediastinal inset (not
into the groove defect), and one in the subcutaneous tis-
sue (Figure 60-4). The skin is closed with deep dermal
sutures and sealed with staples. This closure minimizes
dead space and should be air and water-tight. Suction pro-
vided by the drains at 100 mmHg further minimizes dead
space, encourages fl ap adhesion in the wound, and inhibits
seroma formation. Absolute hemostasis in a clean wound
and continued suction in an airtight closure for 3 to 5 days
is the best environment for primary healing.
Chronic wounds occur in the late post-operative
period any time after the 4th or 5th week of sternotomy.
Although they may present with the same threat as the
acute or sub-acute wound, they usually present as per-
sistent local pain with small amounts of drainage from
the wound edges. Osteomyelitis of the sternum is com-
mon in this group and, after reconstruction, may require
long term intra-venous antibiotic therapy. This is not an
uncommon sequela to wounds initially allowed to close
by VAC therapy alone. These wounds are approached in

RECONSTRUCTION OF THE CHEST – CONGENITAL AND ACQUIRED ANOMALIES AND DEFECTS • 717
a fashion similar to that of sub-acute wounds mandating
thorough debridement of soft tissue and bone and com-
plete foreign body removal, wires, pacing wire remnants,
and fi xation bars or plates if used.
Other muscles considered are the rectus abdominus and
latissimus dorsi muscles. The former are usually second-
ary options and used only if the ipsilateral internal mam-
mary artery has not been employed as a bypass graft as this
forms the superior epigastric artery, which feeds the upper
portion of the rectus. Use of the latter is limited as its range
is limited and the patient would have to be re-positioned.
The latissimus dorsi is a better source as a free fl ap if other
tissues are not available.
The time-tested concept in bone healing by “rigid fi x-
ation” is now coming into play in sternal and chest wall
reconstruction. This concept, adapted from orthopedic
surgery, provides for the most rapid, reliable and strong
healing of bones. Titanium spanning bars have been used
to achieve rigid fi xation and chest wall stability in recon-
structed post-sternotomy dehiscence and infections. It is
particularly helpful in patients with chronic obstructive
pulmonary disease as it not only enhances healing but
signifi cantly decreases morbidity and improves breathing
as noted by the absence of pain and improved chest wall
compliance. Experience is limited in the use of these bars
as they are expensive and somewhat diffi cult to learn
to apply, however signifi cant clinical benefi ts have been
documented. If rigid fi xation is required then this tech-
nique is best. Omentum, as stated earlier, may be used
to protect fresh grafts and unless the titanium bars are
used as a bridge to hold open the mediastinum to reduce
pressure they are not used with omental closures in the
otherwise limited capacity of the mediastinum.
CHEST WALL NEOPLASIA
Carcinomas and sarcomas do occur on the musculoskel-
etal structure of the chest and are uncommon as primary
neoplasms. As they occur they are treated accordingly. If
extirpation is part of the procedure then reconstruction
must be performed to restore form and function, com-
pliance and integrity to the chest wall to allow for nor-
mal respiratory effort and unimpeded circulation. Each
case must be considered on its own merits, evaluating
location of the injury, extent and health and age of the
patient. The techniques applied to post cardiac surgery
reconstruction are similar and will be elaborately dealt
with in the next section.
COMPLICATIONS
Complications are uncommon; however the three, which
occur most often are hematoma, seroma and recurrent
infection. Hematoma is most closely associated with vig-
orous early resumption of anti-coagulant therapy, certainly
desirable after valve and some forms of bypass surgery.
Most cardiac situations can fare well for 72 hours without
resumption of anti-coagulation. Consultation with the car-
diac surgeon and cardiologist will often permit safe anti-
coagulation after reconstruction with low dose aspirin or
Heparin (no more than 300 units/hour) in the early post-
operative period followed by the institution of Warfarin
as early as 48 hours post operative. Clopidogrel and more
aggressive Heparin should be withheld for the fi rst 72
hours.
Seroma formation may occur whenever there is the
presence of large raw open surfaces such as may exist dur-
ing muscle and fl ap mobilization in sternal reconstruction.
This is minimized with the liberal use of initial suction
drains to continual wall suction of about 100 mmHg. In an
average single pedicled muscle fl ap as many as four large
drains are used, commonly 19 French Blake drains and
after 72 hours are progressively discontinued as the drain-
age yield decreases, fi rst subcutaneous, then the muscle
bed, then para-sternal and fi nally axillary. Closed continual
wound suction minimizes dead space and helps with early
fl ap adherence.
Recurrent infection in a properly prepared wound is
uncommon, occurring about 5% or less. Flaps, with the
exception of the omentum, should not be placed in the
presence of frank pus. As little as 48 hours of prepara-
tion can make a 10-fold difference in the incidence of
re-infection. As stated earlier, infected wounds demand
decompression and topical therapy of multiple dressings
or VAC therapy prior to defi nitive closure. In the face
of acute dehiscence and possibly early infection liberal
lavage (pulsatile antibiotic) together with placement
of omentum is usually successful in the preservation of
acutely uncovered coronary bypass grafts. Re-infected
wounds must be re-opened for drainage as all remain-
ing debris and foreign body should have been removed at
the reconstruction procedure these wounds will usually
heal by secondary intension, commonly aided by VAC
therapy. Secondary fl ap reconstruction is generally not
required. However, if not used previously, the omentum
may be a good rescue fl ap as are other muscles such as
recti or latissimus.
Although rare, the most feared complication is injury
to the underlying cardiothoracic structures. Injury to the
bypass graft will result in rapid bleeding which must be
managed emergently. Fro this reason, the anatomy of the
postoperative heart must be recognized. Bypass grafts,
either off the internal mammary artery or saphenous vein,
may be close to, and possibly adherent to, the undersur-
face of the sternum. For this reason, the referring cardio-
thoracic surgeon should be aware of the procedure and
available if needed. Lung injury may result in a persis-
tent and troublesome bronchopleural fi stula if not man-
aged correctly. These patients require initial chest tube
drainage and observation for cessation of an air leak. In
the sub-acute wounds, the mediastinum is often healed
and adherent to the underside of the sternum, therefore,
extra care must be taken to avoid right ventricular tears
and absolute paralysis is a must during this part of the
procedure.

718 • CHAPTER 60
OUTCOMES
Outcomes following chest wall reconstruction have to be
analyzed in terms of safety, cost effectiveness and patient
benefi ts. For reconstruction of sternal wound infections,
the major variables include time to healing and need
for additional surgical procedures. Patients, and their
surgeons, want complications managed expeditiously to
avoid further hospital stay to return to normal activity.
Rigid fi xation plates used in selected candidates at the
primary procedure has reduced the rate of mediastinitis
by 50% and has resulted in earlier and generally pain free
hospital discharges.15
REFERENCES
1. Parham FW. Thoracic resection for tumors growing from
the bony wall of the chest. Trans South Surg Gynecol Assoc.
1898;11:223.
2. Lund FB. Sarcoma of the chest wall. Ann Surg. 1913;
58:206.
3. Julian OC, Lopez-Belio M, Dye WS, et al. The median sternal
incision in intracardiac surgery with extracorporeal circula-
tion: a general evaluation of its use in heart surgery. Surgery.
1957;42:753–761.
4. Shumaker HB, Mandelbaum I. Continuous antibiotic irriga-
tion in the treatment of infection. Arch Surg. 1963;86:384–
387.
5. Lee AB Jr, Schimert G, Shaktin S, Seigel JH. Total excision
of the sternum and thoracic pedicle transposition of the
greater omentum; useful strategems in managing severe
mediastinal infection following open heart surgery. Surgery.
1976;80:433–436.
6. Arnold PG, Pairolero PC. Use of Pectoralis Major Muscle
Flaps to Repair Defects Anterior Chest Wall, Plastic Reconstr
Surg. 1979;63:205.
7. Tang AT, Okri SK, and How MP. Vacuum-assisted closure to
treat deep sternal wound infection following cardiac surgery.
J Wound Care. 2000;9:222.
8. Schulman NH. Plastic Surgery: Clinical Problem Solving.
McGraw Hill Medical; 2009:184.
9. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year re-
view of a minimally invasive technique for the correction of
pectus excavatum. J Pediatr Surg. 1998;33(4):545–552.
10. Moir CR, Johnson CH. Poland’s syndrome. Semin Pediatr
Surg. 2008;17(3):161–166.
11. Clarkson P. Poland’s syndactyly. Guys Hosp Rep. 1962;111:
335–346.
12. Hugo HE, Sutton MR, Ascherman TK, et al. Single stage
management of 74 consecutive sternal wound complications
with pectoralis major myocutaneous advancement fl aps.
Plast Reconstr Surg. 1994;93:1433.
13. Sargent LA, Seyfer AE, Hollinger J, et al. The Healing Ster-
num: A Comparison of Osseous Healing with Wire Versus
Rigid Fixation, Walter Reed Army Medical Center; 1992.
14. Schulman NH, Subramanian V. Sternal wound reconstruc-
tion: 252 consecutive cases. The Lenox Hill experience; Plast
Reconstr Surg. 2004;114:44.
15. Song DH, Lohman RF, Renucci JD, et al. Primary sternal
plating in high risk patients prevents mediastinitis, Eur J
Cardiothorac Surg. 2004;26(2):367–372.

c h a p t e r
Abdominal Wall Reconstruction
Devinder P. Singh, MD / Helen G. Hui-Chou, MD / Ronald P. Silverman, MD, FACS
PATIENT EVALUATION AND SELECTION
The goal of abdominal wall reconstruction is restoration
of the myofascial layer in the anterior trunk. This layer
is highly complex and serves multiple functions. First
and foremost, it is a protective barrier, holding in place
the abdominal viscera. In addition, the abdominal wall
musculature contributes to posture, fl exion, and rotation
of the trunk, respiration, coughing, emesis, defecation,
micturation, and parturition. Defects of the abdominal
wall can compromise any of these functions, cause pain,
or lead to herniation of the viscera. In particular, the risk
of visceral incarceration and subsequent strangulation,
while rare in larger hernias, cannot be ignored due to the
potentially fatal consequences.
Tissue defi cit in the abdominal wall can result from a
wide variety of causes including congenital, cancer, trauma,
burn, and/or infection. The most common cause, how-
ever, is iatrogenic: rates of incisional hernias have been
reported as high as 11% after laparotomy and even higher
in certain subsets of patients (such as open gastric bypass
patients). 1 Primary repair of these incisional hernias car-
ries a very high rate of recurrence (reportedly 40%–50%),
presumably because of undue tension at the repair site. 2
As a result, the gold standard for initial incisional hernia
has become the placement of synthetic mesh to bridge
the gap and reduce tension. 3 Laparoscopic hernia repair
has improved outcomes but has not overcome issues sur-
rounding the use of synthetic materials, patients with mas-
sive defects, or situations where risk for infection at the
surgical site exists.
To help stratify patients based on their risk factors
for surgical site occurrence, the Ventral Hernia Working
Group created a hernia grading system: grade 1 is low
risk and includes patients with no history of a comor-
bid condition or wound infection. Grade 2 includes
patients with a comorbid condition, including tobacco
use, obesity, diabetes, chronic obstructive pulmonary
disease (COPD), and/or immunosuppression. Grade 3
includes patients with potentially contaminated surgical
sites, including those with stomas present, violation of
the gastrointestinal tract such as enterotomy during her-
nia reduction, and/or history of wound infection previ-
ously healed by secondary intention. Grade 4 is reserved
for those patients with an active infection at the hernia
site. 4
In recurrent incisional hernia patients, loss of
abdom inal wall domain can be profound, and plastic sur-
geons are now called upon more and more frequently to
assist with complex reconstruction in these challenging
patients.
PATIENT PREPARATION
Patient preparation begins with the usual preoperative
history and physical examination. Attention should be paid
to prior abdominal procedures and the possible use of allo-
plastic materials. Current symptoms of bowel obstruction
and continence should be sought. Physical examination
should document the quality of the anterior and lateral
soft tissue, the presence and location of any stomas, and
the presence of one or more entero-atmospheric fi stula.
If the bowel is covered with a thin skin graft, an attempt
to manually reduce the bowels back in to the abdomen
while the patient is supine will help evaluate whether the
patient has a loss of domain or not.
Noninvasive imaging such as CT scan or MRI can help
defi ne the extent of abdominal wall loss. A thorough
survey of images in the axial plane can identify additional
smaller areas of herniation or fi stulazation in the obese
or diffi cult to manage patient. Furthermore, additional
information regarding the potential for loss of domain can
be provided.
61

720 • CHAPTER 61
General anesthesia is a standard approach; as such, pre-
operative medical and laboratory workup is performed,
including perioperative cardiac risk stratifi cation, particu-
larly in patients with limited functional capacity or who
otherwise meet indications by clinical history or comor-
bidity. Additional comorbid conditions, including tobacco
use, obesity, diabetes, COPD, and/or immunosuppression,
may require additional attention and preoperative inter-
ventions to improve reconstructive efforts.
Obtaining informed consent includes counseling
patients regarding risks, benefi ts, alternatives, and indica-
tions. This process is a lengthy and complex discussion, and
should include mention of observation of the hernia as an
alternative to surgery, wound complications, hernia recur-
rence rates, use of biologic material implant, and the need
for urgent operative re-exploration if clinically signifi cant
abdominal hypertension develops.
TECHNIQUE
Success in abdominal wall reconstruction is predicated
on a thorough understanding of indications, anatomy, and
treatment options. Several questions must be answered by
the plastic surgeon, including timing (immediate or staged
reconstruction), technique (primary closure, alloplastic clo-
sure, autogenous fl ap closure, or a combination), implant
selection (none, synthetic or biologic), and implant location
(overlay, interposition, inlay, or underlay).
Anatomy
The abdominal wall can be divided into distinct layers:
skin, subcutaneous fat, superfi cial fascia, deep investing
muscle fascia, muscles, transversalis fascia, preperitoneal
fat, peritoneum, and viscera. The muscular layer itself may
be subdivided into the medially located rectus abdominis
muscles, and the laterally located layered triad consist-
ing of external oblique muscles, internal oblique muscles,
and transversus abdominis muscles. The midline fusion of
bilateral rectus abdominus is the linea alba. The medial
and lateral components of each hemi-abdominal wall are
separated by the linea semilunaris (the lateral border of
each rectus sheath). The fascia surrounding the rectus
muscle is known as the rectus sheath and has variable
anatomy: superior to the transverse arcuate line, the rectus
abdominis muscles fi bers are enclosed both anteriorly and
posteriorly in its fascial sheath. The anterior component
of this sheath is comprised of the external oblique fascia
and the superfi cial layer of internal oblique fascia, whereas
the posterior component is composed of the deep layer of
internal oblique fascia and the transversalis fascia. In other
words, above the arcuate line, the internal oblique contri-
bution splits around the rectus muscle to form the sheath.
Inferior to the arcuate line, the rectus abdominis muscles
have fascia only on the anterior surface, which is composed
of the fused external oblique, internal oblique, and trans-
versalis fasciae. As opposed to the superior abdominal wall,
all fascial contributions to the rectus sheath inferior to the
arcuate line are directed superfi cial to the rectus muscle
belly. Posteriorly, one can observe the preperitoneal space
directly.
The abdominal wall derives blood supply from a
variety of sources, both deep and superfi cial. The supe-
rior epigastric artery, which is the terminal continuation
of the internal mammary artery, enters the rectus sheath
at the level of the seventh costal cartilage and arises after
the takeoff of the musculophrenic artery. The deep infe-
rior epigastric artery, a branch of the external iliac artery,
enters the rectus sheath below the arcuate line and gives
off perforating blood supply to the muscle and overlying
abdominal skin. The deep circumfl ex branch of the exter-
nal iliac artery enters the abdominal wall in the region of
the iliac crest. Thoracic and lumbar posterior branches of
intercostal arteries travel between the internal oblique and
transversus layers, and give off direct skin perforators as
well. The superfi cial system is composed of the superfi -
cial epigastric artery, superfi cial circumfl ex iliac artery, and
superfi cial external pudendal artery; all three originate
from the femoral artery.
Nervous supply to the abdomen is particularly important
when striving for functional reconstruction. Thoracic and
lumbar branches of the intercostal nerves travel between
the internal oblique and transversus layers. Knowledge of
this location has direct impact on reconstructive decision
making.
Timing
Reconstruction can proceed either immediately or in a
delayed fashion. Tumor resection and hernia reduction
are common indications for immediate single staged
reconstruction. Staged or delayed reconstruction is
reserved for acute trauma with visceral injury, edema-
tous bowel and elevated compartment pressures, gross
fecal contamination, necrotic bioburden, and/or massive
infection.
The initial management of an acute loss of abdominal
wall domain may be limited in these settings of criti-
cal illness, particularly following penetrating trauma.
“Damage control” laparotomy with temporary abdomi-
nal closure using a negative pressure dressing followed
by applying a split-thickness skin graft directly to the
bowel, has improved trauma/critical care outcomes. 5 As
a necessary consequence, however, the plastic surgeon
is faced with increasingly complex, delayed presen-
tations of massive abdominal domain losses (ie, con-
trolled dehiscence with skin graft directly on bowel).
Skin grafts provide soft tissue coverage; yet they are
not durable or stable, and worse, do not prevent even-
tration ( Figure 61-1 ). Resultant adhesions can be dense,
therefore secondary procedures to excise skin graft and
reconstruct the abdominal wall carry a high risk of com-
plication. It is preferable, if possible, to avoid temporary
abdominal closure with skin grafting and close the open
abdomen during the initial admission, once critical issues
have resolved.

ABDOMINAL WALL RECONSTRUCTION • 721
Technique
Reconstructive options for full-thickness abdominal wall
defects are numerous and span the reconstructive lad-
der, including secondary intention and skin grafting, tissue
expansion, muscle or fasciocutaneous fl aps, fascial grafts,
biologic grafts, components separation, free microvascular
tissue transfer, and composite tissue allotransplantation. 6 , 7
Autologous tissue transfer is the treatment of choice
for abdominal wall defects when synthetic material is
contraindicated.
Tissue expansion has been attempted for most layers of
the abdominal wall. It is most often used in the subcutane-
ous plane when durable soft tissue quantity for coverage is
questionable. Placement between the layers of fascia lat-
eral to the rectus muscles has also been reported. 8 Tissue
FIGURE 61-1. Appearance of abdominal wall after
temporary closure with skin grafting directly to bowel.
Eventration and profound loss of domain are present.
(Copyright Devinder Singh, MD.)
expansion of the abdomen carries the same disadvantages
as expansion in other areas of the body, including the need
for staged reconstruction, risk of peri-prosthetic infection,
device failure, erosion, exposure, or extrusion. This option
also requires the inconvenience of multiple offi ce visits for
the expansion process.
Reliable muscle fl aps described for abdominal wall
reconstruction include the latissimus dorsi, rectus
femoris, and tensor fascia lata muscles. While enabling
transfer of bulky healthy, living tissue into the defect,
there is signifi cant incumbent donor site morbidity.
Furthermore, these fl aps rarely replace very large por-
tions of the abdominal wall. Flaps from the thighs cannot
reliably reach areas above the umbilicus and conversely
latissimus dorsi fl aps can only reconstruct a portion of
the upper abdominal wall. Delay procedures are a useful
adjunct and can increase the territory of these fl aps. Free
tissue transfers such as the free tensor fascia lata myo-
cutaneous fl ap or the free anterolateral thigh fasciocuta-
neous fl ap have also been described for abdominal wall
reconstruction in the most severe cases with massive soft
tissue defi cits. 9
Disa et al. have shown in both animal studies and in
clinical series that fascia lata can be harvested as a free
graft. 10 The graft becomes rapidly vascularized and can be
used in contaminated cases. The donor site morbidity of
these grafts, though less than for most muscle fl aps, is still
signifi cant; and its use, along with the use of muscle fl aps
has generally been abandoned in favor of commercially
available biologic grafts.
The most commonly used biologic grafts are composed
of acellular dermis. Alloderm and Strattice are composed
of human and porcine acellular dermis, respectively, that
have been processed to preserve the natural scaffold of the
dermal architecture. Both materials have been studied in a
variety of applications both in animal models and clinically
for use in abdominal wall reconstruction. These biologic
materials have gained widespread application. They can be
used in temporary abdominal wall reconstruction in criti-
cally ill patients or, more commonly, they can offer defi ni-
tive reconstruction by bridging a fascial defect (inlay or
interposition) as well as reinforcing a primary fascial repair
(underlay or onlay). They are known to resist infection
presumably through revascularization and therefore can
be used in many circumstances where synthetic material
is undesirable. 11
Our preferred technique is a combination of bilateral
component separation (rectus abdominus muscle fl aps)
with biologic reinforcing onlay with Strattice mesh. In
this powerful technique, we fi rst begin by taking down
any intra-abdominal adhesions from the underside of
the abdominal wall to prevent tethering of the fascia to
the viscera ( Figure 61-2 ). Next, undermining of the skin
is performed. Wide undermining of the skin does allow
some fascial advancement, but it is not without a cost:
the further the undermining, the higher the risk of skin
and fat necrosis. We often try to undermine just 1 or
2 cm beyond the rectus to allow for the external oblique

722 • CHAPTER 61
releasing incision and not further unless required for skin
closure.
The aponeurosis of the external oblique is then entered
and divided lateral to the rectus sheath. The fascia is
released superiorly and inferiorly in a vertical direction
parallel to the rectus sheath ( Figure 61-3 ). It is important
to carry this incision all the way over the costal margin
(at this level it is often necessary to divide some of the
external oblique muscle fi bers in addition to fascia) and
several centimeters below the hernia—being careful not
to violate the inguinal ligament ( Figure 61-4 ). Dissection
in this layer is safe precisely because the neurovascular
intercostal bundles lay one anatomic region deeper, in
between the internal oblique and transversus layers. This
relationship has profound impact on the reconstructive
outcome; not only does external oblique fascial release
FIGURE 61-2. Massive abdominal loss of domain after
lysis of adhesions. (Copyright Devinder Singh, MD.)
FIGURE 61-3. Primary closure of defect after bilateral
separation of components (release of external oblique fascia).
(Copyright Devinder Singh, MD.)
allow for medialization and primary closure of the rectus
abdominus muscles, but it also preserves their innerva-
tion and therefore allows for a functional repair.
Useful adjuncts to reduce tension on primary closure
with component separation have been described, such
as elevation of the posterior sheath from the muscle
to allow for some additional advancement. Aggressive
dissection and separation along the avascular plane
between the external oblique and internal oblique lay-
ers can also enable further medial advancement of the
rectus muscle fl aps. Unilateral medial advancement of
up to 5 cm in the epigastrium, 10 cm in the waist, and
3 cm in the suprapubic region is routinely achieved.
Component separation is a powerful technique that
allows the majority of abdominal defects to close, but
close monitoring of intra-abdominal compartment pres-
sures are required. Elevation of the peak airway pressure
while utilizing volume control ventilation is a valuable
intraoperative guide to determine the presence of exces-
sive intra-abdominal pressure.
It is important to place the relaxing incision within
the external oblique fascia rather than in the anterior
rectus fascia because there is no posterior rectus fascia
below the arcuate line. Postoperatively, the patient will
be prone to a bulge in the lower abdomen and recurrence.
Similarly, it is important to identify the correct layer of
vertical release, to preserve the underlying neurovascu-
lar supply to the medialized myofascial fl aps. Finally the
presence of a stoma is not a contraindication to compo-
nents separation. Though peristomal scarring in the sub-
cutaneous place can increase the diffi culty in exposing
the aponeurosis of the external oblique, if the stoma has
been correctly delivered through the rectus, it should sim-
ply medialize with the muscle fl ap after external oblique
fasciotomy. 12
FIGURE 61-4. Close-up of left fasciotomy,
demonstrating medial advancement of rectus muscle and
lateral retraction of cut external oblique muscle. (Copyright
Devinder Singh, MD.)

ABDOMINAL WALL RECONSTRUCTION • 723
Implant Selection
Which implant material to use is a question both contro-
versial and in evolution. Like most, synthetic materials
should be avoided in situations where there is active infec-
tion, lack of reliable skin coverage, bacterial contamination
(such as enterotomy) or substantial comorbidities (such as
obesity, diabetes, smoking, immunosuppression, radiation,
COPD, and malnutrition), which can place the patient at
an increased risk surgical site occurrence. When synthetic
material is chosen, it is preferable to use polypropylene
mesh due to its excellent incorporation provided that an
adequate barrier between the mesh and the bowel can be
established. It is important to note that the commercially
available synthetic and acellular dermal matrices as well
as other types of biologic fascial replacement materials
come with varying amounts of data and the fi eld is rapidly
evolving. The surgeon should use caution when selecting a
product and should base the decision on the best currently
available peer-reviewed literature.
Algorithm
Overall, while many reconstructive options exist, one cur-
rent algorithm for abdominal wall reconstruction involves
the use of immediate components separation when this
can be accomplished with little to no tension along the
suture line. This allows for the reestablishment of an inner-
vated and functional abdominal wall. The suture line is rou-
tinely reinforced with a biologic onlay, as well as any areas
where the existing fascia has been released ( Figure 61-5 ).
When loss of abdominal domain prevents approximation
of the rectus muscles despite component separation, the
biologic material is placed as a bridging graft instead of
as an onlay reinforcement, taking great care to underlap
the existing fascial edges for several centimeters. In these
settings, the surgeon should be mindful that the mesh is
inset under physiologic tension so that any redundancy or
stretch is taken out of the graft to minimize future bulging
( Figure 61-6 ). 11
COMPLICATIONS
Postoperative complications include bleeding, scar, pain,
deep vein thrombosis/pulmonary embolism, and wound
complications. Wound complications are particularly prob-
lematic and common, and can include seroma, skin and fat
necrosis, and wound infection ( Figure 61-7 ). Hernia recur-
rence and/or bulging at components separation donor site
are distinct possibilities, particularly in cases with multi-
ple previous hernia repairs and signifi cant loss of domain.
Visceral injury and abdominal compartment syndrome are
particularly devastating complications.
Specifi cally, to avoid wound complications and expo-
sure of mesh, an attempt is made to minimize the extent of
undermining in the skin fl aps. Perforator-sparing technique
FIGURE 61-5. Demonstration of Strattice biologic mesh
reinforcement of abdominal wall closure. Lateral corners are
sutured to retracted edges of cut external oblique, reinserting
them medially and thereby reconstructing the bilateral donor
site. Note quilting sutures and drains to prevent sub-biologic
seroma. (Copyright Devinder Singh, MD.)
FIGURE 61-6. Demonstration of bridging biologic
Strattice mesh in large abdominal defect. Weaving superfi cial
suture further offl oads tension and helps to re-approximate
myofascial edge to underlying biologic for revascularization.
(Copyright Ronald Silverman, MD.)

724 • CHAPTER 61
FIGURE 61-7. Typical appearance of surgical site
occurrence: wound separation in association with fat and
skin necrosis. Visible at base of wound is exposed biologic
Strattice mesh. (Copyright Devinder Singh, MD.)
during undermining can improve fl ap vascularity and heal-
ing. Minimal access incision techniques including endo-
scopic components separation have also been described. 13
Seroma prevention is of particular concern: obliteration
of sub-biologic potential space with quilting sutures helps
reduce fl uid collection and promotes revascularization
of the biologic mesh. Sub-biologic fl uid collections are
most often asymptomatic and found incidentally; man-
agement is expectant. Additional maneuvers include the
use of submesh closed suction drains, subcutaneous closed
suction drains, removal of sub-Scarpa’s fat in the under-
mined area, and quilting or progressive tension sutures
from the Scarpa’s fascia layer down to the abdominal
wall. Subcutaneous fl uid collections can often be managed
with aspiration and binder compression, or placement of
FIGURE 61-8. After excisional debridement and negative
pressure wound therapy, evidence of revascularization is
evident. (Copyright Devinder Singh, MD.)
FIGURE 61-9. Well-healed autograft onto wound bed
with previously exposed biologic mesh. (Copyright Devinder
Singh, MD.)
FIGURE 61-10. Massive infraumbilical pannus in
association with ventral hernia. (Copyright Devinder Singh, MD.)
image-guided drainage catheters. Aggressive debridement
of the relatively devascularized skin fl aps back to healthy
viable tissues helps to further reduce redundancy in skin,
minimize dead space and promote better wound healing
at the incision ( Figures 61-8 , 61-9 ). The use of routine

ABDOMINAL WALL RECONSTRUCTION • 725
FIGURE 61-11. Inverted-T closure after ventral hernia
repair in association with panniculectomy. (Copyright Devinder
Singh, MD.)
FIGURE 61-12. Incisional wound vacuum-assisted
closure applied to closed incision (layer of semipermeable
petroleum gauze used to protect skin). (Copyright Devinder
Singh, MD.)
incisional vacuum-assisted closure (either placed directly
on the closed incision with a layer of adaptec to protect
skin or segmentally inserted as slender rectangles along
the incision) is being investigated as a means to improv-
ing wound healing ( Figures 61-10 , 61-11 ).14 Finally, there
may be benefi t in routine panniculectomy in conjunc-
tion with abdominal wall reconstruction; panniculectomy
may help to decrease tension on the hernia repair itself
( Figure 61-12 ). Panniculectomy reduces the physiologic
burden of ischemic fat and skin. Furthermore, excess pan-
nus may work as a suction ball valve and contribute to
seroma production; concurrent pannus removal to reduce
seroma formation and subsequent wound complications
is also being studied. We utilize a strict abdominal binder
protocol post-operatively to minimize further complica-
tions after reconstruction. Initially after surgery, use of the
binder is avoided to prevent application of any increased
pressure and ischemia to abdominal skin fl aps. Then,
after 1–2 weeks, patients are instructed to wear a loosely
applied abdominal binder. Finally, after removal of all
indwelling drains, patients are then instructed to wear a
very tight abdominal binder to prevent accumulation of
seroma fl uid.
OUTCOMES ASSESSMENT
Outcomes from abdominal wall reconstruction vary and
depend on technique. Surgeons are usually confronted with
complex abdominal defects in patients with many comor-
bidities including massive obesity or immunosuppression.
Even in these high-risk populations, acceptable results have
been observed with components separation reinforced
with a biologic material as an onlay graft. However, annual
follow-up is warranted in order to identify asymptomatic
recurrent hernias.
As with standard primary closure alone, hernia recur-
rence is a distinct possibility and is most likely due to
excessive tension on the repair despite component separa-
tion. In an effort to reduce the risk for recurrence, place-
ment of a supportive biologic material as an onlay over the
repair is recommended. Not only does the onlay position
allow for reinforcement of primary closure, but we addi-
tionally suture the free edges of the biologic material to
the laterally released external oblique fasciotomy, thereby
reconstructing the bilateral donor site as well. Any instance
where excessive tension is suspected, the fascia should left
open (at least partially) and the biologic can instead be
used as an inlay fascial replacement to bridge the gap.
REFERENCES
1. Mudge M, Hughes LE. Incisional hernia: a 10 year prospec-
tive study of incidence and attitudes. Br J Surg . 1985;72:70.
2. Millikan KW. Incisional hernia repair. Surg Clinic North Am .
2003;83:1223–1234.
3. Luijendijk RW, Hop WC, van den Tol MP, et al. A compari-
son of suture repair with mesh repair for incisional hernia.
N Engl J Med. 2000;343:392–398.
4. Ventral Hernia Working Group, Breuing K, Butler CE,
Ferzoco S, et al. Incisional ventral hernias: Review of the
literature and recommendations regarding the grading and
technique of repair. Surgery . 2010;148(3):544–558.
5. Joels CS, Vanderveer AS, Newcomb WL, et al. Abdominal
wall reconstruction after temporary abdominal closure: A
ten-year review. Surg Innov. 2006;13:223–230.

726 • CHAPTER 61
6. Cipriani R, Contedini F, Santoli M, et al. Abdominal
wall transplantation with microsurgical technique. Am J
Transplant. 2007;7:1304–1307.
7. Selvaggi G, Levi DM, Kato T, et al. Expanded use of trans-
plantation techniques: abdominal wall transplantation and
intestinal autotransplantation. Transplant Proc. 2004;36:
1561–1563.
8. Jacobsen WM, Petty PM, Bite D, et al. Massive
abdominal-wall hernia reconstruction with expanded
external/internal oblique and transversalis musculofascia.
Plast Reconstr Surg. 1997;100:326–335.
9. Silverman RP, Singh NK, Li EN, et al. Restoring abdomi-
nal wall integrity in contaminated tissue-defi cient wounds
using autologous fascia grafts. Plast Reconstr Surg. 2004;
113:673–675.
10. Disa JJ, Klein MH, Goldberg NH. Advantages of autologous
fascia versus synthetic patch abdominal wall reconstruction
in experimental animal defects. Plast Reconstr Surg . 1996;
97:801.
11. Silverman RP, Li EN, Holton, T, et al. Ventral hernia repair
using allogenic acellular dermal matrix in a swine model.
Hernia . 2004;8:336–342.
12. Maas SM, van Engeland M, Leeksma NG, et al. A modifi ca-
tion of the “components separation” technique for closure of
abdominal wall defects in the presence of an enterostomy.
J Am Coll Surg . 1999;189:138–140.
13. Losanoff JE, Richman BW, Jones JW. Endoscopically as-
sisted “component separation” method for abdominal wall
reconstruction. J Am Coll Surg. 2002;195:288; author reply
288–289.
14. Conde-Green A, Chung TL, Holton L, et al. Incisional
negative-pressure wound therapy versus conventional dress-
ings following abdominal wall reconstruction. Ann Plast
Surg. 2012;68(4) epub ahead of print.

62
Reconstruction of the
Perineum and Genitalia
Aaron T. Pelletier, MD / Lawrence J. Gottlieb, MD, FACS
INTRODUCTION
The perineum is technically defi ned as the area between
the anus and the scrotum in the male, and between the
anus and the vulva in the female. Acquired deformities of
the perineum and genitalia requiring reconstruction may
occur due to trauma, burn injury, necrotizing infection,
tumor extirpation, or iatrogenic injury. Congenital defor-
mities such as hypospadias, epispadias, bladder exstrophy,
micropenis, vaginal agenesis, or ambiguous genitalia may
also warrant similar intervention. Patients with gender dys-
phoria may seek genital reconstruction to reconcile their
body with their psyches.
The goals of reconstructive surgery are to provide stable
coverage of wounds, improve appearance and self-image,
allow social interaction, and restore sexual function. It is
important for surgeons to maintain reconstructive aims in
concert with the patient’s needs. Often, reconstruction of
the genitalia requires a complex approach, best addressed
with a multidisciplinary team involving plastic surgeons,
urologists, gynecologists, and psychiatrists. The surgeons
may then choose from a wide variety of options to best
accomplish reconstruction of the specialized tissues of the
perineum and genitalia.
Before proceeding with wound closure, bacteriologic
control is essential. This requires adequate debridement
of all devitalized and infected tissue. Treatment with
appropriate topical antimicrobial agents can often assist in
decreasing bacterial level to less than 10 5 organisms per
gram of tissue. Once this is accomplished, virtually any fl ap
or graft may be employed to provide stable coverage of
the perineal wound. For some patients with open wounds,
nonoperative treatment, ie, healing by secondary intention,
may be appropriate ( Figure 62-1 ).
c h a p t e r
PATIENT EVALUATION AND SELECTION
The initial evaluation should begin with a comprehensive
history and physical examination to elucidate the nature
of the disorder, including the onset and duration of the
problem. It is important to determine the patient’s rea-
sons for seeking reconstruction, as well as his or her level
of expectation. Current and expected urinary and sexual
function needs to be defi ned. For genitalia reconstruc-
tion, what does the patient desire in terms of aesthetics
and function? Do they wish to have the body part for
psychological reasons, with functionality being of sec-
ondary importance, or vice versa? The previous medical
history, including known comorbidities, smoking history,
and cardiovascular health, will determine whether the
patient is a medically appropriate candidate for a recon-
struction that may require several operations. Previous
surgery, especially prior reconstructive attempts, may
change the operative approach. The patient’s occupa-
tion or recreational activities may infl uence the donor
site selection.
In the case of patients with congenital abnormalities, the
workup should include chromosomal analysis, endocrine
screening, androgen receptor levels, and 5-alpha reductase
levels. If it has not previously been done, the genitourinary
system should be evaluated with pelvic ultrasound, urogra-
phy, and CT or MRI as indicated. Patients with congenital
adrenal hyperplasia should have a preoperative electrolyte
panel drawn, as this condition is associated with hypona-
tremia and hyperkalemia.
Psychological screening is also very important. Loss or
absence of genitalia may be associated with depression,
social withdrawal, or other mental illnesses. In the case of
transsexuals seeking gender reassignment surgery, formal

728 • CHAPTER 62
psychiatric evaluation and treatment is a requirement.
Finally, it is important to assess the patient’s social sup-
port system, including partners as well as family, in order
to optimize outcome.
Indications
Patients who have absence, severe defi ciency, deformity,
or dysfunction of their perineum and genitalia secondary
to a congenital malformation, trauma, burns, infection,
malignancy, radiation, or iatrogenic injury are poten-
tial candidates for reconstruction ( Table 62-1 ). Gender
identity disorder patients may become the candidates
for genital construction if they meet predetermined psy-
chological and personality guidelines established by the
FIGURE 62-1. (A) Extensive hydradenitis of the perineal region of a 26-year-old
woman was treated with complete excisional debridement (B) followed by twice daily
dressing changes using topical silver sulfadiazine, with weekly physical therapy and
hydrotherapy sessions to prevent scar contracture. The wound is over 75% healed at
three months (C) and completely healed by 6 months (D).
A
B
D
C
World Professional Association for Transgender Health,
formerly known as the Harry Benjamin International
Gender Dysphoria Association.
Contraindications
Elective complex genital reconstruction is inappropriate
in patients with major cardiac, vascular, or metabolic dis-
eases. The same is true for those with major psychiatric
or psychological problems that would not improve with
this procedure. In this instance, close communication with
the patient’s psychiatrist and/or therapist is invaluable.
Consideration must also be given to the patient’s level of
expectation and ability to deal with potential complica-
tions and potentially unsightly donor site scars.

RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 729
TABLE 62-1. Indications
Congenital deformities
Ambiguous genitalia
Micropenis
Hypospadias
Epispadias
Cloacal deformity
Vaginal agenesis/atresia
Acquired deformities
Trauma
Burn
Infection
Malignancy
Radiation
Iatrogenic
Gender disorders (gender reassignment)
PATIENT PREPARATION
After thorough evaluation of the patient and development
of reconstructive options, a detailed preoperative discus-
sion must specifi cally reiterate the nature of the problem,
the surgeon’s understanding of patient desires and expec-
tations, and available options, including risks, benefi ts, and
any other long-term considerations associated with each
option. Once the operative plan is chosen and agreed upon
by all members of the treating team, informed consent is
obtained.
Most perineal and genital defects are amenable to recon-
struction using local or regional tissue. The vascular leash
of all of the various musculocutaneous, fasciocutaneous,
and perforator fl aps is along the circumference of a 20 cm
diameter circle centered over the perineum ( Figure 62-2 ).
Using these options, an appropriate pedicled fl ap can be
selected depending on the size of the defect, the pres-
ence of radiation damage, availability of donor tissue, and
patient/surgeon preference. Specialized structures such as
the urethra, vagina, or penis have additional reconstructive
goals which may not be adequately replaced with local or
regional tissue and require transfer of distant tissues for
optimal results.
Except for minor repairs and revisions, general anesthe-
sia is usually necessary. Patient positioning is completely
dependent on the operative plan and may vary from prone,
supine, lateral decubitus, frog-leg, lithotomy, jack-knife, or
sequential combinations of each. Adequate planning with
the entire surgical team is critical to ensure proper posi-
tioning of extremities with padding of pressure points to
avoid iatrogenic complications. Finally, it is necessary to
anticipate and communicate to the patient any special
positioning, splinting, or activity limitations that may be
required postoperatively to prevent breakdown of suture
lines or compromise of any grafts or fl aps used in the
reconstruction.
DIEA
SIEA
DCIA
OA
SCIA
DEPA
LCFA
MCFA
PLA
G
A
I
H
F
B
D
C
E
FIGURE 62-2. The pivot points of most loco-regional
fl aps used for perineal reconstruction are located along the
circumference of a 20-cm diameter circle centered over the
perineum. (A) V-Y advancement fl ap, from medial thigh or
inferior gluteal area. (B) Pudendal thigh fl ap. (C) Oblique rectus
abdominis myocutaneous (ORAM) or deep inferior epigastric
artery perforator (DIEP) fl ap. (D) Superfi cial inferior epigastric
artery (SIEA) fl ap or extended superfi cial circumfl ex iliac artery
(SCIA) fl ap. (E) Rectus abdominis musculoperitoneal (RAMP)
fl ap. (F) Gracilis myocutaneous fl ap, shown with vertical skin
paddle. (G) Anterolateral thigh (ALT) fl ap. (H) Gluteal thigh
fl ap. (I) Gluteal fold fl ap. DCIA, deep circumfl ex iliac artery;
OA anterior branch of obturator artery; DEPA, deep external
pudendal artery; LCFA, lateral circumfl ex femoral artery;
MCFA, medial circumfl ex femoral artery; PLA, posterior labial
artery (branch of pudendal artery).
TECHNIQUES: RECONSTRUCTION
OF THE PERINEUM AND FEMALE
GENITALIA
Except for the use of bowel for vaginal reconstruction,
the reconstructive options, armamentarium of fl aps, peri-
operative considerations, and complications are similar
for the perineum, vulva, and vagina, and will be dis-
cussed together. Perineal defects usually involve adjacent
structures and may result following extirpative pelvic
surgery, proctectomy, operative treatment of infl amma-
tory bowel disease, radiation treatment, burns, or devel-
opment of chronic wounds. Perineal wounds are also
frequently associated with cavities that require oblit-
eration. Vaginal reconstruction may be required in cases
of congenital vaginal agenesis or atresia, for example in
Mayer-Rokitansky-Kuster-Hauser syndrome or congenital
adrenal hyperplasia. It may also be required after extir-
pative pelvic surgery for cancer, after trauma or in treat-
ment of male to female transsexuals.
Numerous fl aps from the buttock, thigh, or abdomen
have been described for perineal and vulvar reconstruction.
The choice of technique depends on which tissue is absent,
the size or volume of the defect, available donor sites and
surgeon’s experience, and comfort. The most common fl aps

730 • CHAPTER 62
used are thin fasciocutaneous fl aps based on the pudendal
vascular system, abdominal or thigh perforator fl aps, or the
rectus abdominis or gracilis musculocutaneous fl aps. Large
defects may require a combination of fl aps. Wound closure
is usually straightforward. Reconstruction of a functional
or aesthetically demanding structure frequently requires
multiple operations in a staged fashion.
V-Y Advancement Flap
Advancement of fl aps of the medial thigh or infe-
rior gluteal area in a V-Y fashion provides high-quality,
well-vascularized, innervated skin for vulvar and perineal
defects with very acceptable donor site scars ( Figure 62-2A ).
When designed more posteriorly, the vascular supply of
this fl ap comes from the terminal branches of the super-
fi cial perineal artery and may include perforators of the
descending branch of the inferior gluteal artery. When
the fl ap is designed more anteriorly, its vascularization is
most likely from perforators of the pudendal, obturator,
or medial circumfl ex femoral systems ( Figure 62-3 ). The
versatility and reliability of these fl aps have made them the
new workhorse for vulvar and perineal reconstruction. 1 , 2
Pudendal Thigh (Singapore) Flap
In 1989, Wee and Joseph described the neurovascular
pudendal-thigh fl ap ( Figure 62-2B ), based on the pos-
terior labial artery, which has rich vascular connections
to the deep external pudendal artery, the medial femoral
circumfl ex artery, and the anterior branch of the obtu-
rator artery. 3 This fl ap is elevated in a subfascial plane
over the adductor muscles of the thigh, and transposed
or tunneled to the vulvar defect or into the vaginal
cavity. Monstrey et al. demonstrated that this fl ap can
be safely elevated as an island fl ap. 4 The donor site in
the inguinal crease may be closed primarily and is aes-
thetically acceptable ( Figure 62-4 ). Although the use
FIGURE 62-3. (A) Painful recurrent squamous cell vulvar cancer in an 85-year-old
woman and resultant defect (B) after extirpation. The intraoperative design of a medial
thigh V-Y fl ap (C) and closure following advancement and inset (D).
A
B
D
C

RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 731
FIGURE 62-4. (A) Introital stenosis and clitoromegaly in
a 10-year-old girl with congenital adrenal hyperplasia requiring
incisional release (B). The islandized pudendal fl ap from the
left side is raised (C), transposed (D), and inset to complete
the release (E).
A
B
D
C
E