782 • CHAPTER 66
are present ( Figure 66-3 ). Revascularization should follow
as soon as possible thereafter. It is important to remem-
ber that optimal tissue oxygenation around a wound after
bypass surgery takes 6 to 10 days, and with endovascular
surgery it can take up to 28 days. Premature wound clo-
sure fails to take full advantage of the revascularization.
The connective tissue disorders (eg, systemic lupus,
rheumatoid arthritis, and scleroderma) are frequently asso-
ciated with Raynaud disease that causes distal vasospasm
and cutaneous ischemia. More than 60% of these wounds
have a coagulopathy associated with them. The treatment
of these connective tissue disorders frequently requires
immunosuppressive drugs such as steroids or chemother-
apy agents as well as anticoagulation regimens. The wound
retarding effects of steroids can be partially reversed with
oral vitamin A (20,000 U/day every other day while the
wound is open) and topical vitamin A.
Venous stasis ulcers are three to four times more prev-
alent than arterial ulcers and are caused by local venous
hypertension. The leg has a superfi cial and deep venous
system connected to one another by perforators. Blood
fl ow is largely due to muscle contracture which compresses
FIGURE 66-3. A patient with dry gangrene and no
cellulitis should be evaluated by the vascular surgeon and
revascularized before debridement to save a maximal amount
of tissue (A). However, if there is wet gangrene, surrounding
cellulitis from a necrotic wound base, or necrotizing fasciitis,
the wound should be debrided immediately (B, C).
A
B
C
the veins while directional fl ow is due to the presence of
unidirectional valves that prevent backfl ow. The valves
become incompetent after thrombus formation or with
old age. Surgical treatment of incompetent saphenous or
lesser saphenous vein or of incompetent perforators can
help relieve the local venous hypertension suffi ciently to
allow the wound to heal. The mainstay of venous ulcer
therapy has been compression therapy accompanied by an
exercise regimen that increases venous return to the heart.
Chronic ulcers may benefi t from aggressive wound debri-
dement and application of cultured skin derivatives.
Wound Evaluation
The wound should be assessed carefully by measuring its
size and depth. The area is determined by multiplying the
length and width along the two longest axes perpendicu-
lar to one another ( Figure 66-4 ). The depth and type of
exposed tissue (dermis, subcutaneous tissue, fascia, mus-
cle, and/or bone) should then be established. The wound
should be photographed and referenced with patient iden-
tifi cation data and a ruler. If cellulitis is present, the border
of the erythema should be delineated ( Figure 66-5 ). The
physician can then determine before the culture results are
available whether the initially prescribed antibiotics and/or
initial debridement is successfully addressing the infection.
If the erythema has extended beyond the inked bound-
ary, either the antibiotics are inadequate or the wound has
been inadequately debrided.
The depth of the wound should be carefully assessed
for tendon, joint, or bone involvement. A metallic probe
FIGURE 66-4. The wound area is crudely determined
by measuring the longest horizontal and vertical axes of the
wound that are perpendicular to one another. The product is
then recorded. Then the depth of the wound and the type of
tissue exposed at the base of the wound are also recorded.
A picture of the wound is then taken and remains part of the
medical record.
FOOT AND ANKLE RECONSTRUCTION • 783
( Figure 66-6 ) can be used to assist in evaluating the depth
of the wound. If the probe touches bone, there is an 85%
chance that osteomyelitis is present and a radiograph
should be obtained. It is important to remember that it
can take up to 3 weeks for osteomyelitis to be visible on a
radiograph. Magnetic resonance imaging is considered the
accepted standard in diagnosing osteomyelitis in diabetic
foot ulcerations. However, both magnetic resonance imag-
ing and nuclear scans are expensive and unnecessary if the
bone is going to be directly evaluated during debridement.
These studies are useful if the extent of osteomyelitis in
the suspected bone is unclear or if there is suspicion that
other bones may be involved. If tendon is involved, the
infection is very likely to have tracked along its sheath.
The tendon sheath should be checked for bogginess and
milked toward the open wound to assess whether there
is purulence. If pus appears, then that tendon sheath will
have to be opened along the infected track. If the suspicion
is strong that a distal infection has spread proximally, the
proximal areas where the tendon sheaths are readily acces-
sible should be checked. This can be done with a simple
needle aspiration or the strategic placement of a small
incision and spreading with a straight clamp to the tendon
sheath.
Sensation and motor function must also be assessed. A
careful nerve examination is crucial in traumatic sounds
FIGURE 66-5. A gangrenous forefoot with surrounding cellulitis (A) is initially
debrided to viable tissue. The border of the erythema around the wound is then
delineated with indelible ink (B). The time and date are likewise inscribed. The wound
is then checked 4 to 6 hours later. If the erythema recedes, then the debridement and
antibiotics chosen were appropriate initial treatment. If the erythema progresses beyond
the border, then further debridement is necessary and/or the antibiotics need to be
changed.
A
B
FIGURE 66-6. A metal probe can be very useful for
determining whether bone lies at the base of the wound.
If bone is palpated, then there is an 85% chance that
osteomyelitis is present.
784 • CHAPTER 66
and assessing compartment syndrome. This sensory loss
impairs patients from realizing damage that occurs due to
excessive local pressure from prolonged decubitus position;
from tight shoes, clothes, or dressings; from biomechanical
abnormalities; or from the presence of foreign bodies.
In the infected wound, it is important to know the
source and extent of the infection. Obtaining a radiograph
of the affected area lets the physician know whether the
bone is involved and whether gas is present in the soft tis-
sue ( Figure 66-7 ). If gas is seen within the tissue planes
on the radiograph, then gas gangrene is present and the
wound becomes a surgical emergency. This gas is usually a
byproduct of anaerobic bacteria (usually Clostridium per-
fringens ); it tends to be foul smelling and to travel along the
fascial planes. If there is a question of a deep abscess, ultra-
sound imaging or computed tomography scanning can be
very useful.
If the wound is acutely infected with draining puru-
lence, with odor emanating from it and/or with proximally
ascending erythema, it needs to be debrided immedi-
ately and very aggressively to prevent limb loss or death.
The involved compartments of the extremity should be
released if there is any question that the compartment
pressures are abnormally high. It is important to remember
that just because an extremity presents with gas gangrene,
it should not be summarily amputated, because aggressive
repetitive debridement, with or without hyperbaric oxy-
gen, can often salvage enough of the limb to preserve a
functional extremity. Hyperbaric oxygen has been shown
to be particularly helpful in the control of anaerobic infec-
tions ( Figure 66-8 ).
Aerobic and anaerobic cultures of the wound are
obtained during the debridement by taking pieces of deep
infected tissue and purulence. A swab or superfi cial tissue
culture is of limited use, because it usually refl ects surface
fl ora rather than the actual underlying bacteria responsible
for the infection. One should then debride the wound as
specifi ed above and start broad-spectrum antibiotics after
the deep tissue cultures have been obtained. The antibiotic
spectrum can be narrowed as soon as the culture sensitivi-
ties become available. It is important to remember that a
deep culture may miss up to two thirds of the bacteria
species present. Persisting signs of infection may be due
to inappropriate antibiotics or undrained purulence or
necrotic tissue.
For suspected osteomyelitis, obtain cultures of both the
debrided osteomyelitic bone and the normal bone proxi-
mal to the area of debridement. When only healthy bone
remains at the base of the wound, a one-week course of
appropriate antibiotics usually suffi ces. The exception to
a 1-week course of antibiotics after closure is when the
surgeon suspects that the bone left behind may still harbor
FIGURE 66-7. (A) A diabetic patient with a plantar ulcer rapidly developed a
massively swollen and erythematous foot that had crepitus when examined.
(B) Radiograph revealed gas both on the plantar and dorsum of the foot. The patient
was taken to the operating room immediately for radical debridement. It is important to
remember that while the tissue usually involved is at and above the fascial layer, there
may be elevated compartment pressure underneath that will also need to be addressed.
A
B
FOOT AND ANKLE RECONSTRUCTION • 785
osteomyelitis (eg, calcaneus or tibia). In that case, a lon-
ger course of antibiotic therapy is needed. The appropri-
ate antibiotic course is best determined and monitored by
an infectious disease physician for treatment as well as for
untoward side effects.
The patient’s current and anticipated level of activity
is important to assess to best determined if the leg should
be salvaged and to what degree it should be reconstructed.
If the patient is using the leg in any way, including simple
transfers, then salvage is usually indicated. However, if the
FIGURE 66-8. (A) A patient presented with a gangrenous Achilles tendon. (B) The
necrotic tendon was sharply debrided to shiny underlying tendon. Hyperbaric oxygen
and topical growth factor therapies were started, and the tendon began to granulate (B,
1 week; C, 2 weeks; D, 3 weeks). The Achilles tendon was then successfully skin grafted
and healed completely after 4 weeks (E).
A
D
E
B
C
786 • CHAPTER 66
limb is not going to be used, then strong consideration
should be given to performing a knee disarticulation or
above knee amputation to cure the problem and minimize
the risk of recurrent breakdown.
The complexity of the reconstruction depends on the
ultimate functional goal. For the younger patient or ath-
lete who can tolerate microsurgery, restoration of normal
function is the goal. However, a fancy reconstruction with
a marginally functional leg may limit activity more than a
below knee amputation with an athletic prosthesis. For the
patient who uses the leg simply to transfer, the simplest
solution that will achieve that goal should be chosen even
if it means sacrifi cing part of the foot.
PATIENT PREPARATION AND STAGING
If a wound has responded to aggressive antibiotic therapy,
healthy granulation should appear, edema should decrease
and neo-epithelialization should appear at the wounds
edge. The surgeon may be tempted to proceed to defi nitive
closure after initial debridement of a chronic wound. The
complication rate of single-stage closure is high because
bacterial identifi cation and clearance may not have been
achieved. Studies looking at one-stage amputations (defi n-
itive below or above knee amputations) versus two-stage
amputations (open ankle guillotine amputation followed
by defi nitively closed below or above knee amputations)
yielded a wound complication rate of 21% versus 0%,
respectively. It is therefore useful to wait for closure 2 to
3 days after initial debridement until defi nitive bacterial
cultures are known, glycemic control addressed, and nutri-
tional defi cits corrected. Whenever closing a wound, it
should fi rst be completely re-debrided to ensure that no
residual biofi lm is present. A double instrument setup, con-
sisting of an additional set of instruments, gloves, gowns,
drapes, suction, and Bovie is then used to avoid contami-
nating the reconstruction of the freshly debrided wound
with the just contaminated debriding tools.
Adequate Debridement of Wound
The most important surgical step in treating any wound
is to perform adequate debridement to remove all foreign
material and unhealthy or nonviable tissue until the wound
edges and base consist only of normal and healthy tissue.
Only an atraumatic surgical technique (sharp dissection,
skin hooks, bipolar cautery, etc) should be used to avoid
damaging the underlying healthy tissue ( Figure 66-9 ) that
will provide all the necessary ingredients for the future
healing process. Damaging the wound edge by crushing or
burning may establish a nidus for bacteria to proliferate.
This becomes even more apparent when dealing with the
severely immunocompromised patient with poor blood
fl ow (ie, the renal failure diabetic patient with peripheral
vascular disease).
The goal of surgical debridement is to excise the wound
until only normal, soft, well-vascularized tissue remains.
Using a simple color scale to guide debridement can be
helpful. Debride until the only tissue colors present are red,
yellow, and white. Any tissue of any other color (except
a blue patent vein) should be removed. The tone of the
tissue can also guide the debridement. Getting rid of hard,
indurated soft tissue until only normal soft tissue is left
is ideal. For tendon, any soft liquefi ed tissue should be
removed until only hard shiny tissue is left. For infected
or diseased bone, all soft bone should be removed until
only hard bone with punctuate bleeding is left. Although a
tourniquet is frequently placed as a precautionary measure,
it is preferable to debride the wound without an infl ated
tourniquet, so that the quality of bleeding at the debri-
ded wound edges can be continually assessed. Bleeding
can usually be stopped with gentle pressure with or with-
out topical coagulants. Pinpoint cautery or suture ligation
may be necessary. The debrided tissue should be sent for
pathologic analysis for a specifi c diagnosis of osteomyelitis,
vasculitis, or cancer. Deep tissue cultures should always be
obtained.
For the sensate patient, a regional block allows the
health professional to debride aggressively in the offi ce
under most circumstances. The wound should be debrided
in the operating room if the wound cannot be adequately
anesthetized with a regional block or if the debridement
will lead to bleeding that may be diffi cult to control.
Role of Negative Pressure Dressings
Once the wound is clean and adequately vascularized,
then it can be covered with a negative pressure dressing.
The vacuum dressing applies subatmospheric pressure
to a wound via a closed suction mechanism. 2 The sub-
atmospheric pressure decrease edema, removes wound
healing inhibitory wound healing factors, increases local
blood fl ow, and alters the cellular cytoskeleton. The com-
bination of these factors stimulates the rapid formation
of new tissue. The negative pressure dressing should only
be used on clean, debrided wounds. If the wound is isch-
emic or still has necrotic tissue in it, its use is counter-
indicated. In the former case, it can cause further necrosis
of the wound edges. In the latter case, an infection can
develop.
Negative pressure dressings have changed the way
wounds are currently being treated. 3 It is an excellent ini-
tial dressing after wound debridement because it decreases
edema as well as the local bacterial count. It is an excel-
lent temporizer because it allows the reconstructive sur-
geon time before committing to a defi nite reconstruction.
The reconstructive plans are usually simplifi ed because
the dressing shrinks the size of the wound so that most
wounds can be closed with a combination of local fl aps
and skin grafts. Small wounds can heal by secondary inten-
tion more rapidly with the application of a vacuum dress-
ing. Most wounds develop suffi cient granulation tissue to
cover or fi ll in a defect, so that the wound can then be skin
grafted. The area over an exposed fracture or joint can be
covered with a local or pedicled fl ap while the rest of the
wound is skin grafted.
FOOT AND ANKLE RECONSTRUCTION • 787
TECHNIQUE
Once the wound is clean, the reconstructive ladder
encompasses the following options: (1) allowing the soft
tissue defect to heal by secondary intention, (2) closing
the wound primarily, (3) applying a split- or full-thickness
skin graft, (4) rotating or advancing a local random fl ap,
(5) rotating a pedicled fl ap, or (6) coverage with a micro-
vascular free fl ap. The solution is guided by the patient’s
health, the depth of the wound, the location of the wound,
and the surgeon’s experience. Useful guidelines suggest
FIGURE 66-9. (A) A chronic, nonhealing wound on the thigh of a steroid-dependent
diabetic patient with renal failure. Thorough debridement to healthy bleeding tissue both
at the wound edges and base was required to convert this wound to an acute wound,
so that it can go on to heal (B). The key in debridement is to avoid damaging the residual
tissue by using excellent atraumatic surgical techniques. This means using skin hooks
for retraction (C) rather than crushing forceps, and sharp dissection with a knife (D) rather
than cautery to minimize damage to the tissue left behind.
B
A
C
D
788 • CHAPTER 66
simple coverage if there is no tendon, joint, or bone exposed
within the wound. For more complex defects that involve
exposed vital structures, fl aps (local, pedicled, or free) are
usually necessary. The exception here is that wounds over
the Achilles tendon tolerate skin grafts very well if they
develop an adequate granulation bed. In the foot, creative
amputations that preserve length are often the most rapid
way of obtaining adequate soft tissue envelope with mini-
mal sacrifi ce of function. Using these criteria, more than
90% of all wounds can usually be closed by simple tech-
niques and less than 10% require fl aps.
Because one is dealing with a previously infected wound,
deep sutures should be avoided and the wound should be
closed with as few non-dissolving monofi lament (least
reactive) sutures as possible. This minimizes the amount of
foreign material within the wound that can potentiate sub-
sequent infection. Closing with vertical mattress sutures
creates good tissue eversion along the wound’s edge without
requiring deeper sutures. Interrupted suture closure allows
the surgeon to remove one or two of the overlying sutures
when draining an underlying seroma or hematoma.
Delayed Primary Closure
When closing a wound by delayed primary closure, the
wound edges have to be freshly debrided and the wound
should be closed without tension. Because the leg, ankle
and foot consist of a circumferential soft tissue envelope
around a boney pillar, it is easy to apply excessive circum-
ferential pressure when a wound is closed too tightly. It is
therefore important to check distal arterial pulses pre and
post closure to avoid compromising distal blood fl ow.
Often the skin edges are too far apart to close primarily (ie,
post-fasciotomy, post-fracture). Gradual re-approximation of
the skin edges is possible by serial operations every 2 to
3 days where the skin edges are approximated up to the
point of blanching with horizontal mattress sutures. A vac-
uum-assisted closure (VAC) can be placed over the remain-
ing soft tissue gap to help decrease the edema and make the
surrounding tissue more mobile.
Skin Graft
The skin graft is the simplest of all coverage techniques,
with the only prerequisite being a wound with a bed of
healthy granulation tissue. The superfi cial layer of granu-
lation tissue is removed to ensure that there is minimal
bacterial contamination within the interstices of the gran-
ulation buds. The use of the Versa Jet (a water-based debri-
ding agent) in this setting is ideal because one can precisely
adjust the depth of debridement and rapidly establish a
smooth and level recipient bed. It also removes all residual
biofi lm, reducing the risk of infection.
Preferable donor sites include the ipsilateral thigh, leg,
or instep. The size of the defect is measured to determine
the amount of skin graft needed. The thickness of the har-
vest is set at 15/10000, which is an effective compromise
between adequate take rate and skin graft contraction. If
the skin at the donor site is fl abby or hard to stabilize, the
area should be tumesced by injecting suffi cient normal
saline into the donor site until the entire site is fi rm. The
harvested skin graft can then be meshed (1:1) to allow
for a natural egress of the inevitable buildup of underly-
ing fl uid or blood but need not be stretched as this may
increase healing time. A larger ratio of meshing (ie, 3:1)
is often diffi cult with which to work because it allows the
bridges of skin to rotate so that the epidermis faces the
wound bed. Spraying the recipient site with topical throm-
bin just before placing the skin graft helps control bleeding
at the recipient site. The graft can be secured to the recipi-
ent site using skin clips or absorbable monofi lament suture.
Although a bolster dressing can be used to stabilize the
skin graft over the recipient bed, a VAC is more effective
and provides successful skin graft take rates of as high as
95%. 4 The fresh skin graft is fi rst covered with a nonadher-
ent dressing (silicone or Vaseline mesh). A VAC sponge is
then placed on top and continuous pressure is applied for
postoperative days 3 to 5.
When considering skin grafting over bone, tendon, or
joint, creating a neodermis improves the chances of skin
graft fl exibility and durability. Integra artifi cial dermis
is composed of an overlying removable silicone fi lm (to
prevent desiccation) with an underlying dermal matrix of
cross-linked bovine collagen and chondroitin sulfate. 5 The
dermal layer functions as a dermal template to facilitate the
migration of the patient’s own fi broblasts, macrophages,
lymphocytes, and endothelial cells as well as new vessels.
The sheet of Integra is meshed, cut to fi t the wound, and
affi xed to the site with staples or suture. Over the ensu-
ing week(s), a new cell populated dermis is formed. The
revascularization process is accelerated three- to fourfold
by placing a VAC over the sheet of Integra. Then, the sili-
cone layer can be removed so that a thin skin autologous
skin graft (8/10000–10/10000) can be placed on it.
For wounds on the weight-bearing portions of the foot
(heel, lateral midfoot, under the metatarsal heads), plantar
glabrous skin grafts should be considered. These should be
harvested from the nonweight-bearing portion of the plan-
tar foot: the instep. The instep is infi ltrated with normal
saline to create a smooth but fi rm harvesting surface. The
graft is harvested at a thickness of 30/10000. The instep
should be covered with a thin autograft (8/10000–10/10000)
from the thigh so the donor site can heal without problem.
The glabrous skin graft is then inset over the recipient site
and sewn in with a 5-0 monofi lament suture. Because of
its thickness, the graft takes longer to heal and weight bear-
ing should not be allowed until the graft has completely
healed. The graft may take up to 6 to 8 weeks to heal but
should hold up better than a normal skin graft to the nor-
mal wear and tear that occurs with ambulation.
Local Flaps
Local fl aps are fl aps with unidentifi ed blood supply adjacent
to a given defect that are either rotated on a pivot point
or advanced forward to cover the defect. They come in
FOOT AND ANKLE RECONSTRUCTION • 789
various shapes (square, rectangular, rhomboid, semicircular
or bi-lobed). They usually consist of skin and the underly-
ing fat or skin, fat, and the underlying fascia. It is important
to carefully pre-plan the fl ap by fi rst accurately determin-
ing the size of the defect that needs to be covered after
debridement. Only exposed bone, tendon, nerve, or joint
need fl ap coverage while the rest of the wound can be skin
grafted. This combination of limited local fl ap and skin
graft frequently obviates the need of larger pedicled or free
fl aps. If correctly designed, a local fl ap can also improve
the surgical exposure of the underlying tissue if corrective
bone surgery has to be performed. The harvesting of an
appropriately designed fl ap often improves the exposure
of joints, bone or tendons suffi ciently to avoid making an
extra incision. In addition, local fl aps are a very useful mode
of reconstruction when trying to close a wound within the
confi nes of an external fi xation device.
The ratio of length to width is critical for the survival
of the tip of the fl ap. 6 Because the blood fl ow to the skin
in the foot and ankle is not as developed as in the face,
the length-to-width ratio should not exceed a 1:1 or 1:1.5
ratio. The length-to-width ratio of a fl ap can be increased
when one can Doppler out a cutaneous perforator at the
base of the planned fl ap. To ensure adequate tension-free
coverage, the fl ap should be designed in the area where
the tissue is the most mobile and a slightly larger pattern
should be used than what would anatomically be neces-
sary. A force of 25 mm Hg causes enough venous conges-
tion for fl ap necrosis unless the tension is released within
4 hours. If the fl ap remains pale when inset, it should be
rotated back into its bed and delayed for 4 to 7 days while
it develops more robust blood supply. During that time, a
VAC can be placed on the open wound to ensure that no
edema develops.
Atraumatic technique is a necessary prerequisite when
dissecting the fl ap (bipolar cautery, sharp dissection rather
than cautery dissection, grasping fl ap with skin hooks rather
than pickups, etc.) and when insetting the fl ap (half buried
horizontal mattress or simple vertical mattress stitch with
nonreactive suture). The stitches are biased to bring the
fl ap toward the distal edge of the defect. This minimizes
tension at the most vulnerable distal of the fl ap: its distal
end.
In order to increase the size of the random fl ap beyond
the 1:1.5 ratio without risking necrosis, the fl ap should to
be delayed for 4 to 10 days. The simplest way to accom-
plish this is to incise both sides, and undermine the fl ap.
The incisions are then closed. This interrupts vertical blood
fl ow from the underlying muscle or artery to the center of
the fl ap and forces the blood to fl ow from the base of the
fl ap toward the tip and vice a versa. When the fl ap has
been suffi ciently delayed, the tip is incised and the fl ap is
elevated and rotated into position.
Specifi c Local Flaps
The rotation fl ap is useful on the plantar aspect of the
foot where the fl ap is elevated off the plantar fascia and
rotated into position. It can also be used over the plantar
forefoot, at both malleoli, and on the dorsum of the foot.
If vascular anatomical considerations dictate, the fl ap can
also include underlying fascia and or muscle. The transpo-
sition fl ap is the most frequently used option to cover the
malleoli or exposed tibial-talar fusion around an Ilizarov
frame. The V-Y fl ap is especially useful for defects on the
sole of the foot. It depends on direct underlying perfo-
rators to stay alive and hence is dissected out by simply
cutting through skin fat and fascia without any undermin-
ing. Its advancement is limited to 1 to 2 cm, so that if
the defect is large, double opposing V-Y fl aps should be
considered.
Pedicled Flaps
Pedicled fl aps have identifi able blood vessels feeding
the fl ap. They can contain various tissue combinations,
including cutaneous, fascio-cutaneous, muscle, musculo-
cutaneous, osteo-cutaneous, osteo-musculo-cutaneous
type fl aps, etc. These fl aps work well if they were not
involved in the initial trauma, infection, or radiation fi eld.
Otherwise, the fl aps are stiff, diffi cult to dissect out, and
diffi cult to transfer. In addition, the fl ap has to be soft and
pliable because the vascular pedicle is usually intolerant
of any twisting or turning that occurs when the fl ap is
swung into its new position.
These fl aps are often more diffi cult to dissect and have
a higher complication rate than a free fl ap, which can be
as high as 30% to 40%. Harvesting a pedicled fl ap often
places a donor site defi cit on the foot and ankle that has
to be skin grafted. However, pedicled fl aps allow the sur-
geon to perform a rapid operation with a short hospital
stay that yields excellent long-lasting results. The anatomy
and techniques of dissection are discussed above and in
fl ap anatomy books. 7 It is important to practice these fl ap
on cadaver legs as the dissections are often tedious and
can be diffi cult. The distal reach of the fl ap often provides
insuffi cient tissue so that it is very important to understand
the size limitations of each fl ap.
Lower Leg and Ankle Flaps: Muscle
The lower leg muscles are poor candidates for pedicled
fl aps because most of them have segmental minor pedicles
as their blood supply (type 4) and therefore only a small
portion of the muscle can safely be transferred. The dis-
tal portion of some of these muscles can be used to cover
small defects around the ankle medially, anteriorly, later-
ally. For small and proximal defect, the muscle fl ap can
usually be separated from its distal tendon to minimize the
loss of function.
The extensor hallucis longus muscle (supplied by the
anterior tibial artery) can cover small defects that are as
distal as 2 cm above the medial malleolus. The extensor
digitorum longus muscle and peroneus tertius muscle
(anterior tibial artery) are used for small defects as dis-
tal as 2.1 cm above the medial malleolus. The peroneus
790 • CHAPTER 66
brevis muscle (peroneal artery) can be used for small
defects as distal as 4 cm above the medial malleolus. The
fl exor digitorum longus muscle (posterior tibial artery)
can be used for small defects as distal as 6 cm above the
medial malleolus. The soleus muscle (popliteal, peroneal,
and posterior tibial arteries) is the only type 2 muscle in
the distal lower leg where the minor distal pedicles can
be safely detached and the muscle rotated on its intact
proximal major pedicles to cover large (10 3 8 cm) ante-
rior lower leg defects as distal as 6.6 cm above the medial
malleolus. It can be harvested as a hemi-soleus for small
defects and as an entire soleus for larger defects. The mus-
cles described herein generally have to be skin grafted for
complete coverage. In addition, the ankle has to be immo-
bilized to avoid dehiscence and ensure adequate skin graft
take. The use of external frames can be very useful with
the former and the use of a negative pressure dressing for
the latter.
If a larger fl ap or wider angle of rotation is needed, one
of the three major lower leg arteries with the relevant
minor perforators has to be taken with the muscle fl ap.
The sacrifi ce of a major artery should only be considered if
all three arteries are open and there is excellent retrograde
fl ow. These fl aps are usually harvested distally and there-
fore the accompanying artery depends on retrograde fl ow.
Because these fl aps are larger, the tendon is also taken with
the muscle. It is therefore important to tenodese the dis-
tal portion of the severed tendon to the tendon of a simi-
lar muscle so that the function is not lost. For example,
if the distal extensor hallucis longus muscle is harvested,
the extensor hallucis longus tendon distal to the harvest
should be tenodesed to the extensor digitorum longus so
that the hallux maintains its position during gait. Because
the loss of the anterior tibial tendon is so debilitating, the
distal muscle should not be harvested unless the ankle has
been or is being fused.
Lower Leg and Ankle Flaps:
Fasciocutanous Flaps
Fasciocutaneous fl aps are useful for reconstruction around
the foot and ankle although the donor site usually has to
be skin grafted. 8 The retrograde peroneal fl ap is useful for
ankle, heel, and proximal dorsal foot defects. Its blood
fl ow depends on an intact distal peroneal arterial-arterial
anastomosis with either or both the anterior tibial artery
and/or posterior tibial artery. The dissection is tedious
and it does sacrifi ce one of the three major arteries of
the leg. A similar retrograde anterior tibial artery fl ap fas-
ciocutaneous fl ap (retrograde anterior tibial artery) has
been described for coverage in young patients with trau-
matic wounds over the same areas. Because the anterior
compartment is the only compartment of the leg whose
muscles depend solely on the anterior tibial artery, only
the lower half of the artery can be safely harvested as
a vascular leash. The retrograde sural nerve fl ap (retro-
grade sural artery) is a versatile neuro-fasciocutaneous
fl ap that is useful for ankle and heel defects. The venous
congestion often seen with this fl ap can be minimized if
the pedicle is harvested with 3 cm of tissue on either side
of the pedicle with the overlying skin intact. Problems
with the venous drainage can be further helped by delay-
ing the fl ap 4 to 10 days earlier and tying off the proxi-
mal lesser saphenous vein and sural artery. The inset of
the fl ap is critical to avoid kinking of the pedicle. The
Ilizarov external frame is the safest splint that not only
immobilizes the foot and ankle but also keeps all pressure
off the site by suspending the area of concern in midair.
The major donor defi cit of the fl ap is the loss of sensibil-
ity along the lateral aspect of the foot and a skin grafted
depression at the posterior calf donor site that may pose a
problem if the patient later has to undergo a below knee
amputation. The supra-malleolar fl ap (superior cutaneous
branch of the anterior perforating branch of the peroneal
artery) can be used for lateral malleolar and heel defects
as well as for dorsal foot defects. It can be either har-
vested with the overlying skin or as a fascial layer that
can then be skin grafted. When harvested as a fascial layer
only, the donor site can be closed primarily. Small, fas-
ciocutaneous fl aps based on individual perforators can
also be designed over the row of perforators originating
from the posterior tibial artery medially and the peroneal
artery laterally. Although the reach and size of these fl aps
are limited, they can be expanded by applying the delay
principle. These fl aps have proven to be extremely useful
in the closure of soft tissue defects around the ankle in
patients in an Ilizarov frame because accessibility to the
normal pedicled fl aps or to recipient vessels for free fl aps
is always a problem.
Foot Flaps: Muscle Flaps
The muscle fl aps in the foot have a type 2 vascular pat-
tern with a proximal dominant pedicle and several distal
minor pedicles and are useful to cover relatively small local
defects. The abductor digiti minimi muscle (lateral plantar
artery) is very useful for coverage of small mid- and pos-
terior lateral defects of the sole of the foot and the lateral
calcaneus. Its dominant pedicle is just distal and medial to
its origin off of the calcaneus and it has a thin, distal mus-
cular bulk. The abductor hallucis brevis muscle (medial
plantar artery) is larger and can be used to cover medial
defects of the mid- and hind foot as well as the medial
distal ankle. Its dominant pedicle is at the take-off of the
medial plantar artery and its relatively thin, distal muscular
bulk can be diffi cult to dissect off the fl exor hallucis brevis
muscle. The extensor digitorum brevis muscle (lateral tar-
sal artery) has disappointingly little bulk but can be used
for local defects over the sinus tarsi or lateral calcaneus.
The muscle can either be rotated in a limited fashion on
its dominant pedicle, the lateral tarsal artery, or in a wider
arc if harvested with the entire dorsalis pedis artery. The
fl exor digitorum brevis muscle (lateral plantar artery) can
be used to cover plantar heel defects. Because the muscle
bulk is small, it works best if it is used to fi ll a defect that
can be covered with plantar tissue.
FOOT AND ANKLE RECONSTRUCTION • 791
Foot Flaps: Fasciocutaneous Flaps
The most versatile fasciocutaneous fl ap of the foot is the
Medial Plantar fl ap that is the ideal tissue for the coverage
of plantar defects. 9 It can also reach medial ankle defects.
It can be harvested to a size as large as 6 3 10 cm, has sen-
sibility, and has a wide arc of rotation if it is taken with the
proximal part of the medial plantar artery. It can be har-
vested on the superfi cial medial plantar artery (cutaneous
branch of the medial plantar artery) or on the deep medial
plantar artery (deep branch of the medial plantar artery). It
is preferable to harvest the fl ap with the superfi cial branch
if the artery can be identifi ed by Doppler, because it will
minimally disrupt the existing foot vascular blood sup-
ply. However, if it is to be harvested with retrograde fl ow,
the fl ap should be harvested with the deep branch of the
medial plantar artery. The lateral calcaneal fl ap (calcaneal
branch of the peroneal artery) is useful for posterior calca-
neal and distal Achilles defects. Its length can be increased
by harvesting it as an L shape posterior to and below the
lateral malleolus. It is harvested with the lesser saphenous
vein and sural nerve. Because the calcaneal branch of the
peroneal artery lies directly on top of periosteum, there is a
great danger of damaging or cutting it during harvest. The
dorsalis pedis fl ap (dorsalis pedis and its continuation, the
fi rst dorsal metatarsal artery) can be either proximally or
distally based for coverage of ankle and dorsal foot defects.
A fl ap wider than 4 cm usually requires skin grafting on
top of extensor tendon paratenon which leaves the dorsum
of the foot with less than ideal coverage. The loss of the
dorsalis pedis can pose problems unless the collateral cir-
culation is intact. Because the donor site is vulnerable both
from a vascular and tissue breakdown perspective, this
fl ap is now rarely used. The fi let of toe fl ap (digital artery)
is useful for small forefoot web space ulcers and distal
forefoot problems, although the reach of the fl ap is always
less than expected. The technique involves removal of the
nail bed, phalangeal bones, extensor tendons, fl exor ten-
dons, and volar plates while leaving the two digital arteries
intact. A variation of this technique is the very elegant toe
lsland fl ap where a part of the toe pulp is raised directly
over the ipsilateral digital neurovascular bundle. The fl ap is
then elevated with its long vascular leash to cover a distal
defect. The leash is buried under the intervening tissue.
Microsurgical Free Flap
The microsurgical free fl ap is the most complex recon-
struction that paradoxically enjoys the highest success rate
(.95%). Although it is beyond the scope of this chapter
to cover the technical aspects of microsurgery, I would
refer the reader to many excellent texts 10 that cover the
fi eld. However, it is important to mention some of the key
points for using this type of reconstruction successfully.
The key is to have accessible and open recipient artery
and vein(s) to which the fl ap vessels can be anastomosed.
The recipient artery should not be sacrifi ced by perform-
ing an end-to-end anastomosis; instead, an end-to-side
should always be performed. Two venous anastomoses
should always be performed whenever possible to ensure
adequate outfl ow. The fl ap is then carefully tailored to the
defect and inset. The better the initial fi t, the less likely the
need for later revision of a bulky fl ap. This obviously is very
important because the reconstructed foot will have to fi t
inside a shoe.
The key to choosing the appropriate fl ap is the dis-
tance between the recipient vessel and the existing defect.
Harvesting a larger fl ap and removing normal tissue
between the defect and the recipient vessel can decrease
that distance. The fl aps with longest pedicles are the serra-
tus muscle and the radial forearm fl ap. Muscle fl aps with a
skin graft work the best to cover osteomyelitis and defects
on the sole of the foot. Good donor muscles include the
gracilis from the ipsilateral leg, the rectus abdominus, the
serratus, and the latissimus dorsi. The latter should be
avoided whenever possible as sacrifi ce of the latissimus
dorsi muscle may affect the patient’s ability to crutch walk
and will defi nitely hinder the patient’s ability to propel
himself in a wheelchair. Muscles should be aggressively
trimmed to better fi t a given defect as long as the main
vascular pedicle remains intact.
Fasciocutaneous and cutaneous fl aps work better on
the nonweight-bearing portions of the foot (ie, dorsum of
the foot, ankle). Flaps that are frequently used include the
radial forearm, the lateral arm, the lateral thigh, and the
parascapular. The key in choosing the appropriate fl ap is to
match the depth of the defect with the relative thickness
of the harvested fl ap. This can be diffi cult in obese patients.
Trimmed muscle with skin graft or fascial fl aps with skin
graft may be more appropriate.
COMPLICATIONS
Once the fl ap has been successfully raised, it can still fail
because of tension at the insetting, inadequate blood fl ow,
twisting of the pedicle, hematoma and/or infection, or
coagulopathy. Failure to appropriately evaluate the direc-
tion of arterial fl ow, whether it be antegrade or retrograde,
can lead to fl ap loss. The direction of fl ow is easily deter-
mined with a Doppler by occluding the artery proximally
and distal to the location where the artery is being heard.
Partial or complete occlusion of the vascular pedicle occurs
when the artery and vein feeding the fl ap are twisted as
the fl ap is placed into the recipient site. This occurs if the
base is skeletonized, the vascular pedicle isolated, and the
fl ap is rotated at a sharp angle or if the base is indurated
and infl exible (chronic scar tissue, radiation). Proper fl ap
design and donor site selection should prevent this from
occurring.
Hematoma creates pressure on the fl ap which can limit
venous return and eventually can lead to fl ap necrosis. The
presence of free blood in the deep space is also cause for
concern because the red blood cells themselves release
superoxide radicals that can contribute to fl ap necrosis.
Hematoma can be prevented by meticulous hemostasis,
topical agents, and closed suction drainage. Postoperatively,
792 • CHAPTER 66
REFERENCES
1. Wrobel JS, Mayfi eld JA, Reiber GE. Geographic variation of
lower-extremity major amputation in individuals with and
without diabetes in the Medicare population. Diabetes Care.
2001;24(5):860–864.
2. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a
new method for wound control and treatment: clinical ex-
perience. Ann Plast Surg. 1997;38(6):563–576; discussion
577.
3. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of
vacuum-assisted closure therapy for the treatment of
lower-extremity wounds with exposed bone. Plast Reconstr
Surg. 2001;108(5):1184–1191.
4. Scherer LA, Shiver S, Chang M, et al. The vacuum assisted
closure device: a method of securing skin grafts and improv-
ing graft survival. Arch Surg. 2002;137(8):930–933; discus-
sion 933–934.
5. Moiemen NS, Staiano JJ, Ojeh NO, et al. Reconstructive sur-
gery with a dermal regeneration template: clinical and histo-
logic study. Plast Reconstr Surg. 2001;108(1):93–103.
6. Hallock GG. Distal lower leg local random fasciocutaneous
fl aps. Plast Reconstr Surg. 1990;86(2):304–311.
7. Masquelet AC, Gilbert A. An Atlas of Flaps in Limb Recon-
struction. Philadelphia: Lippincott; 1995.
8. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin
Flaps. 2nd ed. London: Churchill Livingston; 1994.
9. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applica-
tions of the medial plantar fl ap to cover the defects of the
plantar foot, posterior heel, and ankle. Ann Plast Surg. 2003;
50(5):498–503.
10. Serafi n DG. Atlas of Microsurgical Composite Tissue Trans-
plantation. Philadelphia: Saunders; 1996.
it is important to visualize the fl ap and an occlusive trans-
parent dressing facilitates this. If there is any suspicion of
existing hematoma, then the wound should be explored
and the hematoma evacuated. If the fl ap was closed
with interrupted sutures, removal of one or two stitches
allows for evacuation of the hematoma without risking
the disruption of the whole repair. It is important to fl ush
the space with normal saline to get rid of any remaining
hemolyzed blood. If the hematoma cannot be removed in
this way, the patient should be returned to the operating
room for formal evacuation. External pressure by applying
a bandage so that it does not allow for normal postop-
erative soft tissue swelling or too tightly can also impede
blood fl ow.
Infection can damage or destroy a fl ap by increasing the
metabolic demand of the fl ap so that it outstrips existing
blood supply. It is therefore important not to plan a recon-
struction before all signs of infection are gone. This means
that the skin edges are soft with no surrounding indura-
tion or erythema, the pain has diminished, and there are
signs of healing (granulation and neo-epithelialization).
This may require serial debridements that may take up to
1 month before the wound is ready.
Offl oading Techniques
For lower leg wounds, an Unna boot dressing over a skin
graft allows the patient to ambulate immediately postop-
eratively. If a graft or fl ap is in an area (eg, ankle or distal
forefoot) where joint motion could disrupt the graft or fl ap
pedicle, then immobilization with a posterior splint, cast,
or external fi xator and no weight bearing for 2 or more
week is critical for the reconstruction to take successfully.
For heel wounds, the Ilizarov frame is very useful because
it immobilizes the ankle as well as suspends the foot in
midair so that the patient cannot disrupt a graft or fl ap.
If a fl ap is on the plantar aspect of the foot, there should
be no weight bearing until the fl ap has matured (usually
6 weeks). For some patients with challenging wounds, a
cost-effective alternative to Ilizarov frames such as simple
fi berglass or plaster casting may by used.
SUMMARY
Complex lower extremity reconstructions can only be
done effectively by using a team approach which at the
minimum includes a wound care team, a vascular surgeon,
a foot and ankle surgeon, an infectious disease special-
ist, an endocrinologist, and a prosthetist. Wounds need to
be accurately assessed, debrided, and cultured. The vascular
and medical status has to be optimized. The repair is then
dictated by how much function of the leg and foot remain
postdebridement and how the wound can be closed in the
most biomechanically stable construct possible. This may
involve skeletal manipulation, tendon lengthening and/or
partial foot and leg amputations. Soft tissue reconstruction
can be as simple as allowing the wound to heal by second-
ary intention or as complex as coverage with a microsurgi-
cal free fl ap. More than 90% of the wound can be closed
using simple methods from healing by secondary intention
to skin grafting. Utilizing the techniques described in this
chapter should allow for a stable functional wound closure
and decrease the primary and secondary major amputation
rate to below 5%.
c h a p t e r
Postbariatric Surgery
Reconstruction
Jonathan W. Toy, MD, FRCS(C) / J. Peter Rubin, MD
INTRODUCTION
Morbid obesity is an increasing health concern in
the United States. 1 The World Health Organization
defi nes overweight as a body mass index (BMI) of 25
to 29.99 kg/m 2 , with obesity beginning at 30 kg/m 2
( Table 67-1 ). 2 A rise in bariatric surgical procedures due
to the obesity epidemic in the United States has resulted
in growing numbers of patients seeking removal of the
excess skin and fat that remains following weight loss. 3 , 4
Massive weight loss may be described as weight loss in
excess of 50 pounds. Plastic surgeons have had to modify
traditional surgical approaches and techniques in order
to appropriately treat the unique deformities found in
this emerging patient population.
PATIENT EVALUATION
Patient evaluation begins with a complete medical his-
tory. A distinction must be made in the mode of weight
loss. A number of patients have lost weight through gas-
tric bypass or other bariatric procedures, and others have
achieved their goals through diet and exercise alone. This
has important clinical implications as patients undergoing
malabsorptive bariatric surgical procedures are at higher
risk of having nutrient defi ciencies, including protein, vita-
mins, and iron. 5 Key information to obtain regarding the
patient’s weight includes : 6
• Date of bariatric surgical procedure, bariatric surgeon
• Maximum, lowest, and current weight, and BMI
• If patient has reached his or her weight goal
• If any recent (past 3 months) changes to weight status
67
Other important information to obtain includes:
• History of past or current tobacco use, nicotine
replacement therapies
• Prior surgeries
• Prior pregnancies, plans for future pregnancies
• History of prior deep venous thrombosis, pulmonary
embolism, or coagulopathy
• Psychiatric history
• Sequelae of gastric bypass (dumping syndrome,
prolonged emesis)
• General medical issues such as cardiac disease or
diabetes
Screening for nutritional status is important. 7 Many
patients may be nutritionally depleted. Protein intake
by history is assessed, and considered adequate if 70
to 100 g of protein per day is reported. Defi ciencies in
nutrients and vitamins, such as thiamine, folate, B12, and
iron are common, which may be represented frequently
by anemia. 5 , 8 , 9
A generalized physical assessment of the degree of
skin excess, distribution of fat, number and location of
rolls, and the quality and elasticity of the remaining skin
indicates which areas of the body would benefi t from
contouring surgery. Scars from prior surgeries are impor-
tant to document. Ventral hernias and rectus diastasis
must be identifi ed and may be reconstructed in conjunc-
tion with abdominal contouring procedures. Any asym-
metries are pointed out to the patient. A complete set of
standardized photographs is taken.
A proper medical workup is essential. Preoperative
clearances from internists, psychiatrists, and other
794 • CHAPTER 67
TABLE 67-1. BMI and Obesity
Classifi cation
BMI (kg/m2)
Classifi cation
,18.5
Underweight
18.5–24.9
Normal weight
25.0–29.9
Overweight
30.0–34.9
Class I obesity
35.0–39.9
Class II obesity
40.0–49.9
Class III—Morbid obesity
50.0–59.9
Class III—Super obesity
$60.0
Class III—Super, Super obesity
physicians who care for the patient are the rule.
Investigations include a chest x-ray (as indicated), elec-
trocardiogram, complete blood count, coagulation pro-
fi le, pre-albumin, albumin, pregnancy screen in females
of child-bearing age, and a mammogram in accordance
with American Cancer Society guidelines ( Table 67-2 ). 10
Preoperative counseling, which explores the patient’s
goals, expectations, and areas of greatest concern, aids in
patient selection and priority when multiple procedures
are to be performed. Patients must be made aware of the
lengthy scars that occur with large skin resections, and
must be willing to trade a better contour with the resul-
tant scar. Education should encompass pre- and postop-
erative expectations, the length of surgical procedures,
as well as the nature and length of recovery following
multiple procedures.
TABLE 67-2. Key Points in the
Assessment of the Massive Weight Loss
Patient
Detailed medical history, including weight loss history
Nutritional screening and assessment
Physical examination
Degree of skin excess
Body fat distribution
Number and location of rolls
Quality and elasticity of skin
Preexisting scars (quality and location)
Abdominal wall defects, hernias
Standardized photographs
Preoperative consultations (internist, psychiatrist, etc)
Chest radiograph
Electrocardiogram
Bloodwork (complete blood count, coagulation profi le,
pre-albumin, albumin, pregnancy screen)
Mammogram
Additional diagnostic studies as indicated
Patient counseling and education (goals and
expectations)
PATIENT SELECTION
Patients presenting following massive weight loss should
be at or around their goal weight, and be weight stable
for at least 3 months prior to body contouring surgery.
This usually corresponds to a period of 12 to18 months
following bariatric surgery. A BMI higher than 35 kg/m 2
increases the risk of surgical complications. 11 , 12 Aesthetic
outcomes are improved with a lower BMI. In general, a
BMI of 25 to 30 kg/m 2 is ideal. Patients with a high BMI
are counseled to further lose weight. A notable excep-
tion to this guideline is the patient with the disabling
giant pannus, or panniculus morbidus. Such severe soft
tissue excesses of the abdomen, which on resection may
weigh well over 100 pounds, cause signifi cant functional
disability. 9 These patients will generally benefi t from the
removal of abdominal excess in order to improve ambu-
lation, quality of life, hygiene, and further their weight
loss. 13
Patients with severe medical comorbidities, psychiat-
ric comorbidities, unrealistic expectations, and patients
currently using tobacco are preoperatively optimized. Of
note, tobacco use has been shown to increase the risk
of fl ap loss, wound infection, and wound dehiscence. 14
These issues are reassessed at the second preopera-
tive visit and surgical management is offered only once
improved or resolved.
Severe systemic medical disease that would render gen-
eral anesthesia dangerous is a contraindication for body
contouring surgery. Relative contraindications include
active smoking, BMI greater than 35 kg/m 2 , uncorrected
coagulopathies, severe disorders that affect wound healing,
and any medical disease that places the patient at high risk
for surgery.
Psychologic Considerations
Following Bariatric Body Contouring
Massive weight loss is considered by many to be a
“life-altering event.” All patients should be congratulated
on their weight loss. Pre- and postoperative counseling
as to usual postoperative course is essential, including
expectations on recovery, activity, and drain care. Family
and social support will aid in the postoperative recovery
period.
Prior to bariatric surgery, up to one third of patients are
found to have at least one psychiatric diagnosis. 15 Mood
disorders, personality disorders, and poor body image are
most common. Patients with a history of bipolar disorder
and schizophrenia must be offered surgery with caution. 16
TREATMENT
Any major body contouring surgery should be per-
formed in a fully accredited ambulatory care facility
or hospital. 17 With exposure of large surface areas and
prolonged operative times, prevention of hypothermia is
crucial. Active warming, beginning in the preoperative
period, and continuing through surgery, is important.
POSTBARIATRIC SURGERY RECONSTRUCTION • 795
Patient positioning may improve the ease of surgery and
prevent untoward complications secondary to pressure.
Compression on the eyes must be avoided as blindness
has been reported following prone positioning. 18 Neural
and vascular compression may occur, especially in the
extremities. 19
Venous thrombosis prevention must be performed, as
surgeries are lengthy. Early ambulation, mechanical lower
extremity compression devices applied preinduction, and
prophylactic chemoprophylaxis may be used. 20
Length of surgery is an important consideration.
Combining multiple body contouring procedures is fre-
quent and can signifi cantly increase operative time. There
is no consensus on the time limits for body contouring sur-
gery. However, fewer procedures performed and less oper-
ative time generally result in a lower complication rate.
Abdominal Contouring
Along with aesthetic concerns, a hanging abdominal pan-
nus may be symptomatic, causing recurrent intertrigo and
infections in skin folds, hindering ambulation, and mak-
ing intimacy diffi cult. Following abdominoplasty or pan-
niculectomy after massive weight loss, patients indicate
a consistent improvement in body image and subjective
quality of life. 21
A true panniculectomy is a functional operation
designed to relieve symptoms related to an overhanging
abdominal pannus. It is performed in patients with a
higher BMI or more severe medical comorbidities. Skin
fl ap undermining is limited, and the risk of a traditional
abdominoplasty is minimized. No plication is performed
and the umbilicus is commonly sacrifi ced in cases requir-
ing large skin and soft tissue resection. Final scar placement
must be taken into consideration. The inferior margin for
the transverse resection is planned 6 cm superior to the
vulvar commissure in women and from the base of the
penis in men. In keeping the scar low, its ultimate posi-
tion will be hidden in most undergarments. Abdominal
wall reconstruction for ventral or umbilical hernias may
be accessed through the low transverse abdominal inci-
sion. In patients with a favorable BMI, more emphasis
can be safely placed on aesthetic outcomes. In patients
with signifi cant epigastric laxity, a vertical trunk excision
may be combined with the low transverse excision, creat-
ing a fl eur-de-lis type abdominoplasty ( Figure 67-1 ). 22 – 24
Resuspension of a ptotic pubic region to the anterior
abdominal fascia is frequently necessary.
Lower Body Lift/Buttock Contouring
Characteristic fi ndings of the posterior trunk after mas-
sive weight loss include buttock defl ation and ptosis, skin
laxity, and descent of soft tissues in the lateral thighs.
Abdominal procedures alone cannot provide contour
improvement of the abdomen buttocks and lateral thighs
FIGURE 67-1. Fleur-de-lis abdominoplasty. This 38-year-old woman lost 50 kg.
Pre- and postoperative views 12 months following fl eur-de-lis abdominoplasty, including
plication (A,B). Note improved waist defi nition.
A
B
796 • CHAPTER 67
in a single stage. A number of circumferential procedures
have been designed to reshape these areas, including the
lower body lift, belt lipectomy, and circumferential tor-
soplasty ( Figure 67-2 ). 25 – 28 Circumferential dermolipec-
tomy with careful closure of the strong superfi cial fascial
system, along with buttock augmentation with autolo-
gous fl aps, have enhanced aesthetic results and the lon-
gevity of these procedures. 25 , 29 , 30
The design of the operation is critical in determin-
ing overall effects. Planning a resection more superiorly
will allow direct excision of fl ank rolls and emphasizes
the waist. A lower resection will provide a stronger
elevation and vertical pull on the lateral thigh area and
provides greater control in shaping the buttocks with
autologous fl aps. Discontinuous undermining of the
lateral thigh regions increases fl ap mobilization during
closure. 25
Medial Thigh Contouring
The lower extremity must be evaluated as two distinct
areas. Very rarely can excess tissue in the medial and
FIGURE 67-2. Lower body lift. A 39-year-old woman status post 45 kg weight
loss (A, B). After a, fi rst-stage lower body lift with 9 L debulking liposuction of the thighs,
the patient underwent a second-stage vertical medial thigh lift 6 months following initial
procedure (C,D).
C
D
A
B
POSTBARIATRIC SURGERY RECONSTRUCTION • 797
FIGURE 67-3. Vertical medial thigh plasty. A 52-year-old woman status post
60 kg weight loss and prior abdominoplasty. Preoperatively (A). Postoperative views
1 year after revision abdominoplasty and vertical medial thigh lift without having had a
lower body lift (B–D). Often, a vertical medial thighplasty will follow a lower body lift as
a staged procedure.
A
B
C
D
lateral thigh areas be treated by a single surgical pro-
cedure. Circumferential truncal dermolipectomy proce-
dures create a signifi cant pull on the lateral and posterior
thighs, but the medial thighs remain minimally altered.
Choice of procedure in correcting the medial thighs
varies depending on the skin and soft tissue excess, as
well as the patient’s tolerance for scars. In mild cases,
a simple, crescenteric transverse medial thigh excision
may lift the tissues of the proximal medial thigh, leaving
the distal thigh tissues untouched. This technique is reli-
ant on suspension to Colles fascia. 31 , 32 The advantage is a
well-concealed scar. An excisional procedure in a vertical
direction allows more direct control over contour and is
much more powerful ( Figure 67-3 ). 33 The disadvantage
is the visible scar, which may be varied in length. An
excision into the groin crease may be added. 34
798 • CHAPTER 67
Brachioplasty
With massive weight loss, arm defl ation leads to varying
degrees of upper arm deformity, from minor residual fat
deposits to large aprons of skin. The severity of defor-
mity found in these patients requires novel techniques
from the norm to correct. Changes in the arm following
massive weight loss include laxity and displacement of
the posterior axillary fold, residual lipodystrophy of the
arm, and loose, hanging skin.
Selection of procedure is dependent on the distribu-
tion and amount of remaining fat and the extent of skin
excess. In patients with minor skin excess and lipodystro-
phy, liposuction alone may suffi ce. In patients seeking
improvement in contour with minimal scarring, skin
excision limited to the axilla treats the proximal third
of the upper arm. A short-scar brachioplasty, with the
scar extending down only a portion of the upper arm
treats skin laxity more distally but limits incisions. A full-
scar brachioplasty with the scar extending distally to the
elbow is the only treatment for patients with extreme
skin excess ( Figure 67-4 ). 35 , 36 Brachioplasty excisions
may be merged with excisions for upper body lift and
mastopexy procedures.
The major disadvantage with a full-scar brachioplasty
is poor scar formation. The scar may be red and raised
for up to a year postoperatively. Complications include
seroma and lymphoceles, paresthesias, neurapraxia of
the medial antebrachial cutaneous nerve, and wound
dehiscence. 37
Mastopexy and Upper Body Contouring
Volume defl ation, signifi cant ptosis, and fl attening of the
overall breast shape occur following massive weight loss.
The nipple-areola complex is medialized, and lateral chest
rolls develop contiguous with the breast. Varying amounts
of asymmetry between the breasts is the norm. A signifi -
cant amount of skin excess occurs, while parenchymal
volume may be defi cient. Traditional techniques for breast
ptosis are usually inadequate for these deformities. 38 , 39
Goals in mastopexy after massive weight loss include
elevation and repositioning of the nipple-areola complex,
breast reshaping, development of a natural and aesthetic
curve of the lateral breast, volume recruitment if pos-
sible from the lateral thoracic roll, restoration of superior
pole fullness, minimization of scar and proper scar place-
ment, and creating a long-lasting result. 40
The senior author has developed a technique based on
an extended Wise pattern that achieves all of the goals of
mastopexy following massive weight loss ( Figure 67-5 ).
Elevation of the lateral chest excess allows its rotation
medially into the breast mound. De-epithelialization
of the entire Wise pattern and its elevation as an
infero-centrally based dermoglandular pedicle allows
parenchymal reshaping with dermal suspension of the
reshaped breast mound to rib. The overlying remain-
ing envelope of skin and parenchyma is elevated at
approximately 1.5 cm thick and redraped over the newly
reshaped parenchymal breast structure.
Other approaches to mastopexy after massive weight
loss include the rotation-advancement of a supero-medial
pedicle, as well as the simultaneous use of implants for
additional parenchymal volume. 41 Choice of technique
is dependent on breast morphology, patient desires and
expectations, and surgeon preference.
Posterior upper body excess may be addressed with
either a circumferential transverse excision (scar placed
within bra line), or an excision in the midaxillary line. This
procedure may be combined with breast or arm contour-
ing excisions.
Gynecomastia in the Massive
Weight Loss Patient
Although male breast enlargement is most commonly
related to gynecomastia (benign enlargement of male
breast glandular tissue), enlargement following mas-
sive weight loss typically is the result of pseudogyne-
comastia. 42 , 43 Pseudogynecomastia is characterized by
increased subareolar fat without the enlargement of the
breast glandular component. Along with varying degrees
of skin redundancy in the chest, defl ation, prominent lat-
eral chest wall rolls, and medialization and enlargement
of the nipple-areola complex are common fi ndings. 42
Pseudogynecomastia must be differentiated from
true gynecomastia. In patients with minimal skin redun-
dancy and good skin elasticity, liposuction may be
used. Male breast tissue is classically fi brous and dense.
Ultrasound-assisted liposuction techniques are ideal to
break up this fi brous tissue. For patients with moder-
ate to severe skin and soft tissue excess, treatment with
liposuction alone is not adequate. More aggressive exci-
sional procedures that remove skin and soft tissue, while
allowing resizing and repositioning of the nipple-areola
complex are required ( Figure 67-6 ). The nipple-areola
complex may be repositioned on a thin, inferiorly based
dermoglandular pedicle, or as a free nipple graft. 44 Skin
excision of the chest may be followed laterally to remove
the commonly present lateral thoracic roll.
Staging and Combination Procedures
Unlike many patients presenting for correction of specifi c
areas, the postbariatric patient often presents requesting a
number of areas be treated. Factors, including medical sta-
tus, length of procedure, vectors of tension, surgeon expe-
rience and preferences, operative assistance, recovery time,
patient desires, and cost to the patient play a role.
Although no consensus exists, many surgeons believe
that stages should be separated by a minimum of
3 months. A patient should be back to their preoperative
health status prior to a second stage. Regarding maxi-
mum operative time, a 7-hour upper limit has been sug-
gested, but there is no evidence to suggest an absolute
time limit. 45 , 46
POSTBARIATRIC SURGERY RECONSTRUCTION • 799
FIGURE 67-4. A 43-year-old woman status post 60 kg weight loss. Preoperative
views, including markings for brachioplasty (A,B). Characteristic changes following
massive weight loss are seen, including laxity and displacement of the posterior axillary
fold with resultant broadening of the attachment of the arm to the chest wall, residual
lipodystrophy of the arm, and skin laxity and excess. Postoperative views shown
at 4 months (C,D) and 2 years (E,F). Note progression of scar maturation.
A
B
C
D
F
E
800 • CHAPTER 67
FIGURE 67-5. Dermal suspension mastopexy with parenchymal reshaping.
A 51-year-old woman status post laparoscopic gastric banding after 180 lb weight
loss. (A–C) Preoperative views and markings for dermal suspension mastopexy with
parenchymal reshaping. (D–F) Postoperative views at 2.5 years.
C
A
D
B
E
F
POSTBARIATRIC SURGERY RECONSTRUCTION • 801
FIGURE 67-6. Excisional gynecomastia with elevation of the nipple-areola complex
on a dermoglandular pedicle. A 26-year-old man status post gastric bypass with 250 lb
weight loss. (A–C) Preoperative views with markings.
A
B
C
802 • CHAPTER 67
FIGURE 67-6. (continued) (D–F) Postoperative views at 1 year following excisional
gynecomastia with elevation of the nipple-areola complex on a dermoglandular pedicle,
fl eur-de-lis component of abdominoplasty, and medial vertical thigh lift as a second
stage. The fi rst stage was performed 5 months earlier than the second, involving a lower
body lift, panniculectomy, and brachioplasty. Note the marked improvement in chest
contour with good positioning of the nipple-areola complex as well as placement of the
chest scars at the location of the visual inframammary fold. (Reprinted with permission from
Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight loss: detectability of
technique, patient satisfaction, and classifi cation. Plastic Recon Surg. 2008;122(5):1301–1311.)
D
E
F
POSTBARIATRIC SURGERY RECONSTRUCTION • 803
When faced with a patient requesting multiple proce-
dures, the order in which they are carried out may vary
from patient to patient. Assessing an individual’s desires
regarding the areas of the body are of priority is a must.
This, along with surgeon experience and preferences
will help decide the order of procedures. In general, if
a lower body lift procedure is considered, the circum-
ferential truncal procedure should be done in the fi rst
stage. If multiple procedures are performed in a single
stage, opposing vectors of tension should be avoided in
a single stage. This will set the foundation for follow-
ing procedures and may safely be combined with other
upper body procedures.
COMPLICATIONS
The majority of complications from postbariatric body
contouring are wound related. Small areas of wound
breakdown or dehiscence, along with suture extrusion
are common occurrences. Seromas also occur not infre-
quently and may be treated with serial aspiration, place-
ment of a drain, or injection of a sclerosing agent into
the seroma cavity such as doxycycline. 47 The risk of deep
venous thrombosis in the postoperative period should be
reduced with the appropriate use of prophylactic mea-
sures. BMI at the time of surgery may impact complica-
tion rates. 48 Three or more procedures in a single stage
may increase the risk of blood transfusion and increase
the length of postoperative hospital stay. 49 Recurrence of
varying amounts of skin laxity may also occur, sometimes
requiring revisional surgery.
OUTCOMES
Despite the fact that complications are not infrequent in
patients undergoing postbariatric reconstruction, most
patients tolerate the procedures well and are pleased
with the outcome. They understand that surgery is pri-
marily reconstructive in nature rather than cosmetic and
must be willing to accept the risks of wound dehiscence,
seroma formation, and possible systemic complications.
Staging the anatomic locations into more manageable
surgeries facilitates the postoperative course of each.
Patients must also be willing to trade the excess skin and
subcutaneous tissue for long and sometimes unsightly
scars. Outcomes may be improved by selecting patients
with a stable BMI in the 25 to 30 kg/m 2 range and coun-
seling patients who are higher than this level.
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804 • CHAPTER 67
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805
Index
A
Abbe fl aps, 146, 148, 336, 338
ABCD criteria, 69
abdominal fascia, 14
abdominal wall reconstruction
bridging biologic Strattice mesh,
demonstration of, 723f
complications, 723–725
as cross-section, schematic drawing
of, 12f
defect after bilateral separation of
components, 722f
incisional wound vacuum-assisted
closure, 725f
left fasciotomy, close-up of, 722f
massive abdominal loss, 722f
outcomes assessment, 725
patient evaluation and
selection, 719
patient preparation, 719–720
pressure wound therapy, 724f
strattice biologic mesh reinforcement
abdominal wall closure, 723f
demonstration of, 723f
surgical site occurrence, 724f
technique, 721–722
algorithm, 723
anatomy, 720
implant selection, 723
timing, 720–721
ventral hernia, 724f, 725f
well-healed autograft, 724f
abductor digiti minimi transfer, 656
abductor pollicis brevis (APB), 652
abductor pollicus longus (APL), 583
acellular dermal matrices (ADM),
493, 497, 567, 568. See also
aesthetic revisionary breast
surgery, ADM
palatal fi stulae, three-layer closure
of, 153f
Achilles tendon, 780
chronic defect, 21f
skin grafts, 788
acral lentiginous melanoma, 71
acrylic splints, 308
adenoma sebaceum, 80, 88
locating the fi ll port, 497f
nipple-areola reconstruction, modifi ed
skate fl ap, 515f
outcomes, 499
patient evaluation and selection,
494–495
patient preparation, 495
pectoralis major
continued elevation, 496f
elevation, 495f
preoperative markings, 495f
serratus anterior
elevation, 496f
pectoralis major, approximation, 496f
skin closure/drain placement, 497f
skin markings, 520f
superfi cial inferior epigastric
vessels, 509f
superior gluteal artery (SGA), 511f
technique, 495–498
tissue expander
implant reconstruction, 504f
placement of, 496f
TRAM fl ap
lateral aspects, 507f
typical design, 505f
vertical reduction
mammaplasty, 520f
alloplastic craniofacial implants, 31
biocompatibility
surface characteristics, 25
clinical applications
cranioplasty
complications, 30
computer-aided design/computer-
aided manufacturing
(CAD/CAM), 28
patient selection, 28
technique, 28–30
internal orbit reconstruction
complications, 31
technique, 30–31
diagrammatic survey, 26f
facial skeleton augmentation, 31
patient preparation, 31–32
patient selection, 31
technique, 32–35
implant placement, 35
Page numbers followed by f or t indicate figures or tables, respectively.
adenosine triphosphate (ATP) synthesis
in CD4 cell, 43
ADM. See acellular dermal
matrices (ADM)
Advanced Trauma Life Support (ATLS)
protocol, 293
Aeromonas hydrophila, 647
aesthetic revisionary breast surgery,
ADM, 567
augmentation vs. augmentation/
mastopexy, 577t
augmentation/mastopexy, preoperative
views, 572f
breast augmentation, 571f
capsular contracture, 575f, 576f
clinical signs, 577t
complications, 572–576, 577t
FDA restrictions on silicone gel
implants, 567
lamellar separation, intraoperative view
of, 569f
multiple previous revision
augmentations, preoperative
views, 574f
outomes assessment, 576–577
patient preparation, 570–572
patient selection, 568–570
placement of, 569f
postoperative Baker
classifi cation, 577t
regenerative matrix
implant and skin closure, 570f
softness, of implants breast, 572f, 575f
AIN. See anterior interosseous nerve (AIN)
technique, 572
Allen test, 437, 445, 580, 742
alloplastic breast reconstruction, 493
bilateral autologous breast
reconstruction, postoperative
photos, 512f
bilateral pedicle TRAM breast
reconstruction, 506f
complications, 498–499
costochondral junction, 514f
DIEP fl ap, 508f
expander, fi lling of, 497f
inferior pedicle reduction
mammaplasty, 519f
806 • INDEX
ankle reconstruction. See foot/ankle
reconstruction
anotia, 315
anterior compartment secondary, localized
lymphedema, 777f
anterior interosseous nerve (AIN), 621
anterior interosseous nerve (AIN)
syndrome, 625
anterior maxillary sinus, 295
anterior oral cavity, 420
anterior plagiocephaly/brachycephaly.
See coronal synostosis
anterolateral thigh fl ap, 436, 732
antiandrogenic therapies, 473
antibiotics
intraoperative, 302
perioperative, 174
treatment, 303
wound infections, 503
antibody preparations, 42
antithymocyte globulins, 42
Antivan. See lorazepam
APB. See abductor pollicis brevis (APB)
Apert syndrome, 667
apical ectodermal ridge, 663
APL. See abductor pollicus longus (APL)
arm paralysis, 675
arterial anastomosis, 14
arteriovenous malformation, 86
Asch forceps, 258
Asclera, 80
ATLS protocol. See. Advanced Trauma
Life Support (ATLS) protocol
ATP. See adenosine triphosphate (ATP)
atraumatic technique, 789
autogenous bone/cartilage
use of, 25
autologous breast reconstruction
complications, 513
outcomes assessment, 513–515
patient evaluation and selection
adjuvant therapy, 502
risk factors for poor outcomes,
501–502
patient preparation, 502
imaging, 502
operative planning, 502–503
timing, 502
technique
deep inferior epigastric perforator
fl ap, 506–508
free transverse rectus abdominis
myocutaneous fl ap, 504–506
inferior gluteal fl ap, 510
lateral thigh fl ap, 510
latissimus dorsi myocutaneous
fl ap, 503
nipple-areola reconstruction, 513
pedicled transverse rectus abdominis
myocutaneous fl ap, 503–504
recipient site and insetting,
512–513
alloplastic craniofacial implants (Cont.)
materials
acrylic biomaterials, 26
ceramic materials, 27
hydroxyapatite, 27
metals, types, 27
polymers, 25–26
polymethyl methacrylate/
polyhydroxyethyl
methacrylate, 27
polysiloxane (silicone), 26
porous polyethylene, 26–27
ramus and body, 35
alloplastic options, 241
alloplastic reconstruction, 316, 493, 499
alopecia, 471
anterior hairline, double-croissant
expander, 477f
complications, 480
differential tissue expander, 479f
double-croissant expander, 478f
etiopathogenesis and treatment, 472t
hair replacement therapy, 472–473
hair restoration for vertex scalp, 474f
hair restoration surgery at anterior
hairline, 474f
outcome assessment, 480
patient evaluation and selection,
471–472
patient preparation, 473
technique, 473
hair transplantation, 473
follicular unit extraction,
475–476
follicular unit micrografts and
minigrafts, 473–475
pedicled hair-bearing tissue
fl aps, 476
tissue expansion
expanded juri fl ap, 476–477
hippocratic baldness,
reconstruction, 477–480
temporal recession, 477
unit follicular grafts, recovery of, 475f
alpha-2 agonist, 62
alpha-smooth muscle actin (a-SMA), 2
alprazolam (Xanax), 62
alveolar fractures, 272, 276
alveolus, malignant lesions of, 423
American Society of Anesthesiologists
(ASA), 61
ASA Physical Status (ASA PS), 61
amino-amides (lidocaine, bupivicaine), 63
amino-esters (procaine, benzocaine), 63
Andy Gump deformity, 445
anesthesia for plastic surgery. See plastic
surgery, anesthesia
anesthetic complication, 61
angel’s kiss, 81
angiographic embolization, 271
angiography, 209
anisocoria, 238
Rubens fl ap, 510
superfi cial inferior epigastric artery
fl ap, 508
superior gluteal fl ap, 508–510
transverse upper gracilis fl ap,
510–512
autologous fat grafting, use, 498
avascular necrosis, 612
B
basal cell carcinoma (BCC), 71
Basilar fractures, 587
Battle’s sign, 295
BCC. See basal cell carcinoma (BCC)
Becker adjustable breast implants, 560
Bell palsy, 457–459
Bennett fractures, 608
benzodiazepines, 62, 64
preoperative, 62
seizures, 63
Bernard-Burrow-Webster fl ap, 340
beta-adrenergic receptor, 92
bicoronal fl aps, 300
bicoronal synostosis, bilateral
FOAR, 175f
bilateral gluteal fold fl aps, 738f
bilateral necrotic heel ulcers, 756f
bilateral NOE fractures, 311
Bilhaut-Cloquet procedure, 670
bilobed fl ap, 330
bladder catheter, 62
blindness, 275
complication of midface
fractures, 275
steroid injection, 92
traumatic/iatrogenic, 303
blood glucose levels, 93
blood transfusion, 805
blood-typing techniques,
developments, 379
blue rubber bleb nevus syndrome, 82
blunt Boies elevator, 258
BMI. See body mass index (BMI)
body lift, lower, 798f
body mass index (BMI), 795
bone distraction, benefi t of, 184
bone fl ap segment, 171
bone graft absorption, 446
bone healing, 205
bone retention, 453
bone transport techniques, 752
bony nasal pyramid/dorsum,
reconstruction, 327
Botox injection, 460, 467
botulinum toxin, 764
bowel obstruction, risk, 403
boxer’s fracture, 607
brachial plexus, 673, 674
electrophysiologic studies
electromyography, 676
nerve conduction studies, 676
INDEX • 807
inframammary incision, 548f
outcomes assessment, 554
patient evaluation and selection,
541–543
patient preparation, 543
incision placement, 543
axillary, 544
inframammary, 543
periareola, 543
transumbilical, 544
pectoralis major muscle division, 550f
subpectoral pocket dissection, 550f
technique, 547
axillary, 550–551
inframammary, 547–548
periareola, 548–550
breast cancer, 481
adjuvant therapy, 489
American Joint Committee on Cancer
(AJCC), 487
batwing mastopexy lumpectomy, 485f
contrast-enhanced breast MRI, 487f
full-thickness parenchymal
resection, 484f
high-grade DCIS with central
necrosis, 482f
invasive ductal carcinoma low-
power, 486f
LCIS high power view, 485f
risk factors, 481–482, 482t
invasive carcinoma, 486–489
lobular carcinoma in situ, 485–486
in situ breast cancer, 482–485
standard lumpectomy, 484f
breast deformity, 563
breast development, 555
breast hypoplasia, 563
breast implants, 542
breast mound, re-creation of, 513
breast pain, chronic, 553
breast parenchyma, 518, 534
lack of violation, 544
pectoralis muscle, 548
subglandular dissection, 545
breast radiation, 488
breast reconstruction, 502, 523. See also
alloplastic breast reconstruction;
autologous breast reconstruction
myocutaneous fl ap, 396
tissue expander, 560
breast reduction, procedures, 533
bridle wire technique, 284
broken blood vessels, 89
broproliferative scarring, 5
buccal mucosa, 432
bulging/trapdoor effect, 325
bupivicaine, 63
burn reconstruction, 101
with bilateral hand burns, 107f
burn contracture of elbow limiting
fl exion, 109f
complications, 110
dense axillary contractures, 108f
extensive burn alopecia, 105f
extensive neck contractures, 106f
extensor tendon exposure of
thumb, 107f
face reconstruction, 103f
hypertrophic scarring of lower
lip complex causing lip
eversion., 104f
multiple z-plastys, 110f
outcomes assessment, 110
patient evaluation and
selection, 101
patient preparation, 101
surgical treatments
breast burn reconstruction
breast contractures, 108
nipple-areola deformities, 108–109
head and neck burn reconstruction
cheek contractures and
hypertrophic scarring, 103
eyebrow defi cit, 104–105
eyelid contractures, 102–103
forehead scarring, 104
nasal scarring and deformities, 103
neck contractures, 105
perioral contractures, 103
scalp defects and alopecia, 103–104
lower extremity burn reconstruction
foot contractures, 109
fourth-degree burns, 109
popliteal fl exion contractures, 110
perineum burn reconstruction, 109
reconstructive ladder, 101–102
direct closure, 101
skin grafts, 101–102
tissue expansion and fl aps, 102
Z-plasty, 101
upper extremity/hand burn
reconstruction
axillary adduction contractures, 106
boutonniere deformity, 108
digital fl exion contractures,
107–108
dorsal hand contractures and
hypertrophic scarring, 106–107
elbow contractures, 106
exposed bone/joints/tendons,
105–106
hand reconstruction, 105
web contractures and
syndactyly, 108
z-plastys, 102f
C
CABG. See coronary artery bypass
graft (CABG)
CAD. See computer-assisted design (CAD)
calcineurin inhibitor tacrolimus
(FK 506), 39
Caldwell’s view, 295
epidemiology and classifi cation,
673–674
global left brachial plexus
paralysis, 685f
gunshot injury to the neck, 678f–679f
historical review, 673
infraclavicular plexus, exposure, 681f
injury, mechanisms, 674
management
closed injuries, 678–679
free muscle transplantation, 684–686
nerve grafting, 682
nerve transfers, 682
extraplexus neurotization, 684
intraplexus neurotization, 682–684
neurolysis, 682
open injuries, 677–678
postoperative management, 686–687
secondary procedures, 686
surgical exploration, 679–681
multiple root avulsions, 677f
outcomes, 687
patient evaluation
pain management, 675–676
physical examination, 675
positioning of patient, 680f
preganglionic injury, clinical
example, 674f
radiological studies, 676–677
right brachial plexus palsy
secondary, 683f
right Horner syndrome, 675f
supraclavicular and infraclavicular
plexus, 681f
upper extremity, 686f
vascularized ulnar nerve,
harvesting, 682f
brachial plexus exploration, 680
brachioplasty, 801f
brain abscesses, 250
brain, re-organization/plasticity of, 45
BRCA1/BRCA2 gene, 482
breast augmentation
axillary incision with saline
implant, 551f
complications, 551
aesthetic complications, 552–553
capsular contracture, 552
implant rupture, 551–552
local complications, 553
uncommon complications, 553
dual-plane technique, 546f
implant position, 544
dual plane, 545–546
subglandular, 544–545
subpectoral, 545
implant selection
round vs. shaped, 547
silicone vs saline, 546–547
size, 547
smooth vs. textured, 547
inframammary approach, 549f
808 • INDEX
cheek resuspension, 227
chemotherapy, 427, 489
Cherry angiomas, 89
chest wall defects, reconstruction, 713
chest–congenital/acquired anomalies,
reconstruction, 713
acute post cardiac surgery wound,
treatment of, 715–717
chest wall neoplasia, 717
complications, 717
omental inset to mediastinum, 715f
outcomes, 718
patient evaluation, 714–715
sternal wounds, algorithm, 714f
titanium bars, screw and release
pins, 715f
unipedicle pectoralis major
inset, 716f
vacuum assisted closure (VAC)
therapy, 713
Chiari malformations, 167
chin implants, extended, 35
chlorohexidiene mouthwash, 301
chronic obstructive pulmonary disease
(COPD), 719
circumfl ex scapular artery, 407
Clark’s level IV, 75
clawing produces, 657
cleft lip repair, 125, 189
complications, 131
outcomes, 131
patient preparation, 125–127
techniques
bilateral cleft lip repair, 129–131
gingivoperiosteoplasty (GPP), 131
unilateral cleft lip repair, 127–129
cleft lip, secondary deformities, 141
cancellous bone grafting, oronasal
cleft, 151f
gingivoperiosteoplasty utilizing soft
tissue fl aps, 150f
lip switch procedure, 147f
local vermilion, recruitment of, 146f
malalignment of white roll, 144f
orbicularis oris deformities, 144
palatal fi stula, two-layer closure, 151f
pants-over-vest closure prevents scar
depression, 145f
pharyngeal musculature, 149f
philtral scars, diamond-shaped
excision, 143f
primary cleft lip repair, white roll
alignment, 143f
recalcitrant palatal fi stulae, regional
fl aps, 152f
scar abnormalities, 142–143
scar margin, vermilion produces
notching, 144f
secondary bilateral cleft lip
deformity, 148f
small palatal fi stula, 151f
spectrum of, 142f
vermilion defi ciencies, 144–146
vermilion, malalignment of, 143–144
cleft lip/palate patients
orthognathic surgery, 204
cleft nasal deformity, 154–157, 154f
cleft nose deformity
poor tip projection, illustrating, 155f
cleft palate, 133
complications, 137–138
double-opposing z-plasty,
markings, 137f
hard palate, chronic fi stula of, 138f
infant, intraoperative
photograph, 134f
infant with Pierre Robin
sequence, 134f
nasoendoscopic image, 134f
nasopharynx, photograph, 138f
outcomes assessments, 138–139
palate cleft, prenatal ultrasound, 134f
palate impression, appliance
fabricated, 135f
patient preparation, 134–135
patient selection, 133–134
secondary deformities, 149
oronasal fi stulae, repair of, 150
palatal fi stulae, 150–152
technique, 136–137
Veau-Wardill-Kilner repair, completed
intraoperative view of, 136f
von Langenbeck repair, completed
intraoperative view, 136f
cleft rhinoplasty, suture techniques, 156f
clefting, of palate, 121, 189
Clostridium perfringens, 784
CMC. See carpometacarpal (CMC)
CMV. See cytomegalovirus (CMV)
cold sensitivity, 304
Colles fascia, 799
collumelar lengthening techniques, 157f
Coloboma-type defects, 194
colon cancer, 740f
composite tissue allografts (CTAs), 38, 39
compound motor action potential
(CMAP), 627
computer-aided manufacturing (CAM)
programs, 199
computer-assisted design (CAD), 199
conchal cartilage, 328
concomitant facial fractures, 245, 247
condylar fractures, 281, 288, 309, 310
condyle, transplantation, 451
cone beam computed tomography, 220
congenital breast deformities, 555
embryology and development, 555–556
hyperplastic disorders, 556
developmental breast asymmetries,
557–560
giant fi broadenoma, 556
gynecomastia, 557
polythelia and polymastia, 556
virginal hypertrophy, 556
calvarial bone, 274
calvarial reconstruction, 369–379
calvarium crest, 274
CAM. See computer-aided
manufacturing (CAM)
camptodactyly, types, 667
capillary vascular malformations, 79, 80
capsular contracture, 499
capsulorrhaphy, 569
carbon dioxide laser
light, 80
photodynamic therapy, 75
vaporization, ulcerated cutaneous
lymphatic vesicles, 85
carcinogenesis, 419
Caroll-Girard screw, 226
carpal tunnel release (CTR), 627
carpal tunnel syndrome (CTS), 622
Guyon canal compression, 629
nonoperative therapy, 629
carpometacarpal (CMC)
dislocations, 607
joints, 586
cartilage grafts, 321, 328, 329
cartilaginous septum, 326
cefazolin, 520
cephalometric radiograph, 198f
cephalometric tracings, 199
cephalosporin, 520
cerebrospinal fl uid (CSF)
fi stula, 222
urinary strip, 230
leakage, 209, 217, 271, 275, 292
otorrhea, 229
certifi ed hand therapists (CHTs), 701
cervical spine stabilization, 293
cervicofacial fl ap, 352
cervicofacial fl aps
for triangle I defects, 347
cervicofacial lymphatic
malformations, 84
Charles procedure, 774
cheek reconstruction, 343
aesthetic subunits of cheek, 344f
combination fl ap reconstruction,
351f–352f
complete triangle I defects, 346f
complications, 352
facial relaxed skin tension lines, 344f
large triangle II defect, 348f
microvascular, 349f
outcomes assessment, 352
patient evaluation, 343–345
patient preparation, 345
reconstructive triangle
classifi cation, 344f
techniques, by triangular subunit, 345
buccomandibular triangle, 347
combination zone defects, 347–352
infraorbital triangle, 345–347
preauricular triangle, 347
using tissue expansion, 350f
INDEX • 809
Cottle test, 326
Crane principle, 760
cranial bone exposure, 103
cranialization, 222
craniofacial clefts, 189
complications, 195
lateral facial clefts, 195f
lower midline facial clefts, 194f
outcome assessments, 195–196
patient evaluation and selection, 189
classifi cation, 190–192
epidemiology, 189
etiology, 189–190
patient preparation, 192
type I, midline facial clefts, 192
type II, paramedian facial clefts, 192
type III, orbital facial clefts, 192
type IV, lateral facial clefts, 192
rare craniofacial clefts
surgical classifi cation, 191f
Tessier classifi cation for, 190f
simple bifi d nose, patients, 193f
technique, 192
type I, midline facial clefts, 193–194
type II, paramedian facial clefts, 194
type III, orbital facial clefts, 194–195
type IV, lateral facial clefts, 195
craniofacial skeleton reconstruction, 279
alloplastic implants, diagrammatic
survey, 26f
craniomaxillofacial surgeon, 250
awareness, 245
cranioplasty, 28, 377
complications, 30
computer-aided design/computer-aided
manufacturing (CAD/CAM), 28
patient selection, 28
technique, 28–30
craniosynostosis, 167
bilateral FOAR for bicoronal
synostosis, 175f
bilateral fronto-orbital reconstruction,
171f–174f
classifi cation of, 168t
complications, 175–176
craniofacial dysostosis syndromes, 168t
elevated intracranial pressure, CT
fi ndings, 168f
metopic groove, 169f
metopic notch, 169f
outcomes assessment, 176
patient evaluation and selection, 167
patient preparation, 167–168
technique
coronal synostosis, 170–174
lambdoid synostosis/posterior
deformational plagiocephaly,
174–175
metopic synostosis, 168–170
sagittal synostosis, 170
crippling fi stulae, 150
Crohn’s disease, 736, 737
CSF. See cerebrospinal fl uid (CSF)
CTS. See carpal tunnel syndrome (CTS)
Cupid’s bow, 128, 142, 146, 148, 193
marking, 97
secondary deformities
long lip, 147
short lip, 146–147
tight lip, 147–148
wide lip, 148–149
cutaneous fl ap, 791
Cutler-Beard fl ap, 358
cytomegalovirus (CMV) infection, 40
D
Davydov procedure, 732
DCIS. See ductal carcinoma in situ (DCIS)
Debakey forceps, 271
debulking procedures, 97
deep circumfl ex iliac artery, 510
deep inferior epigastric perforator (DIEP)
fl ap, 11, 502, 506, 565
complications, 14
muscle preservation, 510
patient evaluation and selection, 12–13
patient preparation, 13
superfi cial inferior epigastric artery,
preoperative view of marked
patient, 15f
technique, 13–14
deep space infections, 617
dental compensation, 198
dental occlusion, 182
dermal suspension mastopexy, 802f
dermatitis/fungal growth, 517
dermatofasciectomy, 694
dexamethasone, 64
dexmedetomidine, 65
diabetic patient
bilateral lateral plantar metatarsal
ulcers, 781f
with plantar ulcer, 784f
diabetic peripheral polyneuropathy, 780
Dieffenbach technique, 321
DIEP fl ap. See deep inferior epigastric
perforator (DIEP) fl ap
Digital Imaging and Communications in
Medicine (DICOM) images, 220
distal interphalangeal, palmer, 595
distal phalanx fractures, 588
dog ears, 375
deformities, 345
dolichocephaly. See sagittal synostosis
Doppler probe, 14–17, 436, 580, 759
Doppler signal, 23, 781
Doppler ultrasound, 331
dorsal nasal fl ap, 330
dorsal root ganglion (DRG), 674
dorsal tongue fl ap, 432
Doyle splints, 259
ductal carcinoma in situ (DCIS),
481, 482
hypoplastic disorders, 556
pediatric breast deformities, 555
Poland syndrome
autologous tissue transfer, 564–565
fat transfer by injection, 565
clinical classifi cation, 563
etiology, 563
expander and implant
reconstruction, 564
pathognomonic of, 563
treatment, 563–564
tuberous breast deformities, 560
classifi cation, 561–563
clinical features, 561
etiology, 561
congenital hand anomalies, 663
bilateral hands, amniotic band
syndrome of, 668f
cleft hand deformity, 666f
constriction ring syndrome, 672
differentiation, failure of
arthrogyposis, 667–668
camptodactyly, 667
clinodactyly, 667
pediatric trigger thumb, 668–669
radioulnar synostosis, 670
syndactyly, 667
duplication
central polydactyly, 671
radial (preaxial) duplication, 670
triphalangeal thumb, 670–671
ulnar (postaxial) polydactyly, 671
embryology, 663
future directions, 672
overgrowth, macrodactyly, 672
patient evaluation, 663
central defi ciency, 666
radial longitudinal defi ciency,
664–666
transverse defi ciency, 664
ulnar defi ciency, 666–667
thumb duplication, classifi cation
of, 670f
thumb hypoplasia, classifi cation of, 664f
trilobed fl ap repair method, 669f
type IV thumb hypoplasia, 665f
ulnar (postaxial) polydactyly,
classifi cations of, 671t
undergrowth, 671
consciousness, 64
conservative management, 308
continuous positive airway pressure, 164
contralateral prophylactic
mastectomy, 494
COPD. See chronic obstructive
pulmonary disease (COPD)
corneal shields, 272
coronal endoscopic brow, 460
coronal synostosis, 170–174
coronary artery bypass graft (CABG), 502
corticocancellous iliac crest/rib grafts, 447
cosmetic surgeons, 66
810 • INDEX
eczematous skin, 251
Eikenella species, 618
elbow contractures, 106
electrocautery, 372
electromyography (EMG), 627
embryogenesis, 113
Emory/Agris-Dingman dissector, 551
endermologie, 773
endoscopic approach, 226
endo-tracheal tube (ETT), 64
endovascular laser ablation, 82
enophthalmos, 32f, 238
enterotomy, 723
epilepsy, severe mental disorder, 229
epithelium, 431
Epstein-Barr virus (EBV), 42
Erickson model block, 199
estimated blood volume (EBV), 176
Estlander fl ap, 338
exophthalmos, 235
extensive hydradenitis, of perineal
region, 728f
extensor carpi radialis longus (ECRL),
583, 624, 652
extensor carpi ulnaris (ECU), 583
extensor digitorum communis
(EDC), 624
extensor indicis proprius (EIP), 583
extensor pollicis brevis (EPB), 583
extensor pollicis longus (EPL), 583
external canthus-buccal commissure, 182
extracellular matrix (ECM)
components, 2
eyeglass-supporting auricle, 315
eyelid
abnormalities, 243 (See also eyelid
defects)
ancillary testing, 355
cheek junction, 225
thinner skin, 344
upper lid ptosis surgery, 366
eyelid defects, 355
reconstruction, 355
eyelid ectropion, 303
eyelid reconstruction/ptosis repair
complications, 361–364, 366–367
congenital ptosis
clinical example of, 367f
eyelid switch fl ap, 360f
clinical case, 361f
Fasanella-Servat procedure, 366f
frontalis sling procedure, 367f
marginal refl ex distance, measurement
technique, 364f
Mueller’s muscle, 358t
Mustarde rotational cheek fl ap, 362f
clinical example, 363f
outcomes assessment, 367–368
partial-thickness, 359f
patient evaluation, 355
patient preparation, 356, 365
patient selection, 364–365
surgical technique, 365
frontalis sling, 366
levator aponeurosis repair and
advancement, 365–366
tarsal conjunctival mullerectomy, 366
technique
eyebrow/eyelash reconstruction, 361
upper/lower eyelid, full-thickness
loss, 356–361
upper/lower eyelid, partial-thickness
loss of, 356
treatment algorithm for defects, 357t
unilateral tripier fl ap, 359f
F
face reconstruction, 103f
facial artery myomucosal (FAMM) fl ap
closure of large palatal defect, 152f
facial asymmetry, 179, 312
facial clefting, 189, 191
facial fractures, current treatment
adequate exposure of orbital fl oor, 241f
anterior view of apex, 235f–237f
bones, anterior view, 234f
bony wall, medial view, 234f
cantilever bone graft treatment, 225f
complications
cerebrospinal fl uid fi stula, 229–231
ectropion, 231
facial hypoesthesia, 231
secondary displacement, 231
condylar fractures, 229f
coronal sections of CT scan, 239f
depressed frontal sinus fracture,
endoscopic treatment, 220f
entrapped inferior rectus muscle, CT
suspicious, 226f
facial injuries, 220f
frontal sinus
cranialization of, 223f
obliteration, 222f
high subcondylar fracture, 230f
inferior orbital rim, 242f
intraoral examination, 220f
isolated left orbital fl oor fracture,
preoperative photograph, 243f
naso-orbital-ethmoidal injury, 223f
NOE. See naso-orbitoethmoid (NOE)
orbital blowout fracture, preoperative
photograph, 240f
outcomes, 231
patient evaluation, 219–221
patient preparation, 221
treatment
frontal sinus fractures, 221–222
frontobasal fractures, 222–223
mandible fractures, 228–229
maxillary fractures, 227–228
nasal fractures, 227
naso-orbitoethmoid fractures,
223–225
Dupuytren diathesis, 694
Dupuytren nodules, 693
Dupuytren’s disease, 691, 694, 697, 698
characteristic, 692f
complications, 697–698
diseased cords, 694t
epidemiology, 691–692
incisions utilized in surgery, 696f
operative technique, 694
anatomy, 694–696
dissection, 696–697
incision, 696
postoperative care, 697
wound closure, 697
outcomes assessment, 698
palmar and digital fascial structures, 695f
patient evaluation/selection
patient presentation and
diagnosis, 692
surgical indications and
contraindications, 692–693
patient preparation
operative considerations, 693–694
preoperative considerations, 693
spiral cord, intraoperative dissection
of, 696f
surgical options, 693t
Durkan test, 623
dynamic skin tensions, 1
E
ear keloid, recurrences, 8f
ear reconstruction, 315
alloplastic ear framework, 320f
autogenous ear framework,
fabrication, 318f
complications, 321–322
costocartilaginous framework,
deformation, 321f
microtia severity, classifi cation of, 316f
outcomes assessment, 322
partial auricular reconstruction, 321
patient evaluation, 315
patient preparation, 315–316
prominent ear deformity, 320
antihelical fold, 320f
skin graft, 318f
skin necrosis, 322f
technique, 316
alloplast reconstruction, 319
autologous reconstruction, brent
technique for, 317–318
Firmin technique, 319
Nagata technique, 318–319
prosthetic reconstruction, 319–320
temporoparietal fl ap, elevation, 319f
x-ray fi lm, 317f
earlobe deformities, 321
early active motion protocols
(EAMPs), 703
ectropion, 231
INDEX • 811
fl exor digitorum superfi cialis (FDS), 583,
621, 654
fl exor pollicis longus (FPL), 583, 657, 704
fl exor tendon injuries, 702
fl oating palate, 269
FOAR. See fronto-orbital advancement
reconstruction (FOAR)
foot reconstruction, 755
foot/ankle reconstruction, 779
complications, 791–792
offl oading techniques, 792
lower extremity wounds, principle
etiologies, 779–786
atherosclerotic disease, 781
wound evaluation, 782–786
patient evaluation and selection, 779
patient preparation and staging,
786–787
negative pressure dressings, role of,
786–787
wound, adequate debridement, 786
technique, 787–791
delayed primary closure, 788
foot fl aps
fasciocutaneous fl aps, 791
muscle fl aps, 790
local fl aps, 788–789
lower leg/ankle fl aps
fasciocutanous fl aps, 790
muscles, 789–790
microsurgical free fl ap, 791
pedicled fl aps, 789
skin graft, 788
specifi c local fl aps, 789
foregut, 116
forehead reconstruction, 369–379
forehead scars, 104
fosaprepitant dimeglumine, 64
FOXC2 gene, 771
frontal bone, zygomatic process, 291
frontal craniotomy segment, replacement
of, 249
frontal nerve block, 366
frontal sinus fractures, 245. See sinus
fractures, frontal
anterior table, internal fi xation of, 248f
anteroposterior displaced fracture, 249f
complications, 250–253
facial fractures, current treatment
concomitant, 247
frontal sinus fracture treatment
algorithm, 246f
nasofrontal outfl ow tract injury,
computed tomographic
diagnosis, 246f
free fi bula osteocutaneous
reconstruction procedure, 252f
indolent infectious complications,
treatment algorithm, 251f
mucocele, 252f
nasofrontal outfl ow tract, 247f
outcomes assessment, 253
outfl ow tract injuries, 247t
patient evaluation and selection, 245
patient preparation, 245–246
photographic and CT depiction, 253f
sequelae of improper, 250f
surgical treatments, 246
ablation (exenteration), 247–248
cranialization, 248–249
obliteration, 249–250
osteoneogenesis, 248
reconstruction, 248
frontalis sling, 367
frontonasal process, 125
frontonasomaxillary buttress, 291
fronto-orbital advancement reconstruction
(FOAR), 171
frontozygomatic, 228
frontozygomatic suture, 173
full-thickness skin grafts (FTSG), 102
local fl ap, 107
Furlow palatoplasty, 137, 159
G
galeal scoring, 372
Galetti articulator, 199
gangrene, dry, 782f
gangrenous Achilles tendon, 785f
gangrenous forefoot, with cellulitis, 783f
gastrocnemius, 755
gene expression profi ling, 489
genital herpes, 593
gentle downward traction, 527
Gillies fan fl ap, 339, 340
Gillies fl ap, 340
Gillies modifi cation, 340
Gillies principle, 225
Ginestet hook, 227
gingivoperiosteoplasty (GPP), 131
Girdlestone arthroplasty, 769
glomus tumors, 82, 85f
gluteal abscess, inhalation injury, 735f
gluteal artery perforator (GAP) fl ap
breast reconstruction, 16
gluteal fold fl ap, 732–737
gluteal thigh fl ap, 732
Goldenhar syndrome, 177
Gorlin syndrome, 71
gracilis fl ap, 732, 766
for ischial pressure sore coverage, 766f
gracilis muscle fl ap, 466, 754f
graft-versus-host disease (GVHD), 40
GranuFoam Silver, 53
Graves disease, 33f
Grayson ligament, 695
gunshot wounds, 678
Gustillo classifi cation, 749
Gustillo III defects, 757
Guyon canal, 623, 624
gynecomastia, 800
excisional, 803f–804f
physiologic, 557
orbital fractures, 225–226
orbitozygomatic fractures,
226–227
zygomatic fracture, 227f
facial fractures, pediatric, 305
anatomic differences/special fracture
patterns, 305
complications, 312–313
fourth dimension, 306–307
outcome, 313
patient preparation, 307
patient selection, 307
physiological, 305–306
psychological, 306
technique
bone substitutes, 308–309
condylar fractures, 309–310
conservative management, 308
fi xation hardware, 308
frontal bone fractures, 312
management/repair, principles of,
307–308
mandible fractures, 309
mandibulomaxillary
fi xation, 308
nasal fractures, 310
naso-orbitoethmoid fractures,
310–311
orbital fractures, 311–312
surgical management, 308
zygomaticomaxillary complex
(ZMC) fractures, 311
facial incision healing, 302
facial nerve, 268, 345
motor function, 294
recovery, 459
facial skeleton, 233
augmentation, 31
patient preparation, 31–32
patient selection, 31
technique, 32–35
facies equine, 271
fasciocutaneous fl aps, 790, 791
fasciocutaneous free fl aps, 440
fat grafting, use, 498
FDS. See fl exor digitorum
superfi cialis (FDS)
fi brofatty node–bearing tissue, 426
fi broproliferative scars, 6
fi bula free fl ap, 408–412
fi ne-needle aspiration (FNA) biopsy, 381
Firmin technique, 319
Firmin techniques, 322
fi rst dorsal interosseous (FDI), 627
fi sh mouth, 162
Fitzpatrick’s classifi cation, of sun-reactive
skin types, 70t
fl eur-de-lis abdominoplasty, 797f
fl exor carpi radialis (FCR), 583, 621
fl exor carpi ulnaris (FCU), 582, 623
fl exor digitorum profundus (FDP),
621, 652
812 • INDEX
radial nerve palsy splints, 708f
scar management products, 708f
soft tissue management
edema and scar, 708–709
splint to resolve intrinsic
tightness, 710f
tendon transfers/free muscle transfers,
706–707
ulnar nerve anticlaw splint, 707f
hand, physical/radiologic
evaluation, 579
Bennett fracture, 589f
Brewerton view, 587f
fi nger cascade, tenodesis effect, 583f
fl exor digitorum superfi cialis, 585f
Gamekeeper’s thumb with chip
fracture, 589f
history, 579
ligamentous injuries
fi ngers—metacarpophalangeal joint,
589–590
fi ngers—proximal interphalangeal
joint, 590
thumb, 589
MCP joint fl exion, 585f
motor examination
motor nerve tests, 582
relevant anatomy
median nerve, 583
radial nerve, 583
ulnar nerve, 582–583
musculotendinous units
dorsal forearm, 584
volar forearm, 584–586
observations, 579–580
fi nger position at rest, 580f
osseous injuries
distal phalanx fractures, 588–589
metacarpal fractures, 586–588
middle phalanx fractures, 588
proximal phalanx fractures, 588
palmaris longus tendon, 585f
radiologic examination
additional imaging/special
views, 586
classifi cation, 586
imaging, 586
Roberts view, 587f
sensory examination, 581–582
thumb proximal phalanx, fracture
dislocation of, 588f
vascular examination, 580–581
without sensory nerve overlap,
areas, 581f
hand transplant recipients, 44
hand/wrist fractures, 603
carpal bones fractures, 609t
carpus fractures, techniques
capitate, 611
hamate, 610–611
lunate, 611
pisiform, 611
scaphoid fractures, 609–610
trapezium, 610
trapezoid, 611
triquetrum, 610
chronic ulnar-sided wrist pain,
MRI, 611f
complications, 611–612
dynamic ex-fi x device, 606f
hemi-hamate reconstruction
pre-/postoperative imaging, 606f
Jahss maneuver, clinical
photograph, 607f
outcomes assessment, 612
patient evaluation and selection, 603
patient preparation, 604
scaphoid waist fracture, 610f
small fi nger metacarpal neck
fracture, 607f
spiral fractures of index and middle
fi nger metacarpal, 608f
techniques
distal phalanx, 604
MCP joint, fracture-dislocations of,
606–607
metacarpal fractures of digits,
607–608
metacarpal fractures of thumb,
608–609
PIP joint, fracture-dislocations,
605–606
proximal/middle phalanx
condylar fractures, 605
extra-articular fractures,
604–605
pilon fractures, 605
hard tissue replacement, 377
Hayton-Williams disimpaction
forceps, 273
head/neck cancer, 379
cervical metastases sites, 380f
comments, 412–415
common sites of cancer, 386f, 387f
diagnostic workup, 381
biopsy, 381
fi ne-needle aspiration, 381
incisional/excisional, 381
sentinel node biopsies, 381–382
imaging tests, 383
nuclear magnetic resonance
imaging, 383
technetium scan, 383
distribution of fl aps, 415t
donor segment of jejunum, 409f
fl oor of mouth, 390f, 395f
hard/soft palates, vertical imaginary
plane, 385f
inferior portion of neck, 393f
intraoral cancers, 383
general principles, 380
hematogenous spread, 381
lymphatic spread, 380
unknown primary, 381
H
hair addition prosthesis, 472
hair follicles, 476
hair restoration for vertex scalp, 474f
hair restoration surgery techniques, 471
role of plastic/reconstructive
surgeon, 471
hair transplantation, 473
hair-bearing skin, 331
hair-bearing temporal scalp graft, 104
hair-bearing tissue, 392
Hall-Findlay technique, 522
hand anomalies. See congenital
hand anomalies
hand infections, management, 613
acute paronychia in emergency
room, 615f
collar button abscess, 617
deep space infections, 617
felon/necrotic tissue, 616, 616f
general principles, 613
herpetic whitlow, 614–616, 616f
human bites, 617–618
intravenous drug abuse, large
subcutaneous abscess, 619f
necrotizing fasciitis, 618–619
nosocomial infections, 619
offending organisms, 614t
osteomyelitis, 618, 618f
paronychia, acute, 613–614
patient with large subcutaneous
abscess, 615f
pyogenic fl exor tenosynovitis, 617f
pyogenic tenosynovitis, 616–617
radial and ulnar bursa infections, 617
resistant organism infection, treatment
of, 619
septic arthritis, 618
therapeutic regimens, 614t
hand injuries, rehabilitation, 701
digital goniometer, 702f
EAMPs for fl exor tendon zones
I–V, 704t
evaluation/systems review, 701–702
extensor tendon laceration, dynamic
extension splint, 707f
extensor tendons, 705–706, 705f, 705t
fl exor pollicis longus (FPL),
704–705
fl exor tendons, 702–704, 702f
fracture management
hand and wrist, 708–710
fractures, treatment, 709t
hand therapy, 701
intrasynovial fl exor tendon injury,
progressive force exercises, 705f
keloid scar, elastomer mold for, 709f
medial nerve C-bar to prevent fi rst web
space contracture, 707f
nerve injury/repair, 707–708
PROM in dorsal blocking splint, 703f
INDEX • 813
facial formation
schematic depiction, 118f
facial/pharyngeal arch development,
diagramatic sectioned
view, 119f
fetal mandible
cartilages and membranous
ossifi cation, 123f
mandible/temporomandibular joint,
development, 123f
masticatory apparatus, 122–123
mouth, 116–118
neural crest cells, derivatives, 116t
neural crest streams emanating from
rhombomeres (r1-r8), 117f
neural crest tissue
(ectomesenchyme), 114
neural crest tissue segments, fate map
schematic depiction, 117f
non-cleft side, lip hight measuring, 128f
noordhoff triangular fl ap, 129f
orofacial clefts, 118f
palate, 119
facial and pharyngeal arch
development, 119
diagramatic sectioned view, 119f
palatoschisis, 121–122
pharyngeal system
derivatives of, 120t
possible anomalies of, 121t
pharyngeal arches, 118–119
pharyngeal pouch derivatives, schematic
depiction, 119f
pharyngeal system
derivatives of, 120t
possible anomalies, 121t
rotation advancement repair, typical
markings, 128f
skull, 122
skull bone origins, 122f
taping, cleft segments, 127f
temporomandibular joint, 123
healing process, 4
heel, nonhealing wound, 757f
helical rim defects, 321
hemangiomas, 79, 91
bilateral cleft nasal repair, 98f
biopsy, 94
with central dermal and subcutaneous
component, 92f
chest, 94f
complications
avoidance and management,
99–100
extensive cervico-facial
scarring, 100f
general techniques, 95–96
laser considerations
KTP and Nd:YAG lasers, 95
pulsed yellow dye lasers, 95
left eyelid, 93f
natural history, 91
noninvoluting congenital
hemangioma, 95f
nonsurgical therapy, 91–92
pulsed yellow dye laser, 96f
recent medical advances, 92–93
redundant upper lip tissue, 99f
region-specifi c techniques
cheek/parotid, 98–99
ear, 98
lip, 97–98
nasal, 96–97
periorbital, 96
rhinoplasty approach to nasal tip, 97f
surgical treatment
patient evaluation and selection, 93
patient preparation
early involutional phase, 94
late/complete involutional
phase, 94
mid-involutional phase, 94
noninvoluting congenital
hemangiomas (NICH), 95
proliferative phase, 94
rapidly involuting congenital
hemangiomas (RICH), 94
timing, 93–94
ulcerated, 94
hemi-abdominal wall, 720
hemifacial microsomia (HFM)
syndrome, 177
bone elongation, 181f
bony hypoplasia, distraction
vector, 182f
complications, 182
corticotomy, diagram, 180f
epidemiology, 177
facial asymmetry, microtia, soft
tissue defi ciency, and chin
deviation, 178f
neurovascular bundle, internal cortical
layer, 180f
outcomes assessment, 182–187
pathogenesis, 177
patient evaluation and selection
classifi cation, 177–178
clinical presentation, 178–179
patient preparation, 179
postoperative period, 181–182
preoperative frontal view, 184f,
185f, 186f
technique, 179
semirigid external devices, 181
vectors of distraction, 181
unidirectional external device, 183f
hemiglossectomy defects, 439
hemitransfi xion, 259
hemopneumothorax, 674
HER2/neu protein, 489
herpes simplex virus (HSV-1) infection,
457, 593, 615
herpetic infections, 614, 615
Hippocratic baldness, 477
MRI scan, 384f
treatment
latissimus dorsi fl ap, 396–399
pectoralis major fl ap, 388–392
stage I disease, 385
stage II disease, 386–387
sternocleidomastoid fl ap, 387–388
tongue fl ap, 385
trapezius fl ap, 392–396
laryngopharyngectomy, 412f
mastoid attachment of muscle, 394f
maxillofacial area, recurrent tumor
of, 384f
melanoma, lymphocintigram of, 383f
microcoupler applicator device, 408f
microvascular free fl ap
reconstruction, 399
fi bula free fl ap, 408–412
jejunal free fl ap, 400–404
radial forearm free fl ap,
404–406
scapular free fl ap, 406–408
mouth/tongue, right lateral fl oor, 397f
MRI scan, 384f
nodal classifi cation, 388t
occipital artery, 393f
oral cavity/oropharynx
primary tumor classifi cation, 388t
stage grouping, 388t
paddle of skin, 390f
pharyngeal fi xed tumor, 398f–399f
radial artery, 410f
radical resection of tumor, 391f
recurrent carcinoma of soft tissues,
405f, 406f
recurrent epidermoid carcinoma, 403f,
407f, 413f
recurrent squamous cell carcinoma,
400f, 401f, 402f
resection of tumor, 389f
resection of ulcerated
carcinoma, 411f
skin paddle, 410f, 414f
of pectoralis major fl ap, 396f
sternocleidomastoid (SCM)
muscle, 392f
three-ring controlled syringe, 382f
trapezius muscle, 404f
head/neck embryology, 113
bilateral cleft lip, 127f
bilateral lip repair, markings, 130f
cleft lip, microform, 126f
cleft palate variations, 122f
coronal sections, 121f
craniofacial development, 114–116
dentition, 123
early embryology, 113–114
embryogenesis
diagrammatic synopsis of, 115f
schema, 114f
embryonic disk elevating neural
folds, 115f
814 • INDEX
treatment
latissimus dorsi fl ap, 396–399
pectoralis major fl ap, 388–392
stage I disease, 385
stage II disease, 386–387
sternocleidomastoid fl ap, 387–388
tongue fl ap, 385
trapezius fl ap, 392–396
intraoral examination, 295
intraoral reconstruction
anterior palatal fi stula, 433f, 434f
complications, 437
healed split-thickness skin graft, 432f
hemi-soft palate, exposure/resection
of, 442f
marginal mandibulectomy
defect, 434f
near-total glossectomy
specimen, 438f
outcomes
glossectomy defects
partial, 439–440
repair, 437–439
total, 440
hard palate defects, 440–441
soft palate defects, 441–442
tongue reconstruction,
prosthetics, 440
patient preparation, 431
patient selection, 431
photograph demonstrating, 435f, 436f
technique
pectoralis major myocutaneous
(PMMC) fl ap, 432–436
primary repair, 431–432
soft tissue reconstruction with free
fl aps, 436–437
split-thickness skin grafts, 432
tongue fl aps, 432
total orbitomaxillectomy defect,
photograph demonstrating, 441f
total tongue reconstruction, 439f
intravenous thiopental, 379
ipsilateral ribs, 318
ischial pressure sore coverage
inferior gluteus maximus island
fl ap, 766f
inferior gluteus thigh fl ap, 766f
ischial tuberosities, 764f
ISG Frameless Stereotactic Guidance
System Wand, 211
isofl urane, inhalation agent, 65
isolated defects, 332
isolated orbital roof fractures, 226
Ivy loops, 285
J
jaw surgery, nonrigid fi xation, 201
jejunal free fl ap, 400–404
jersey fi nger, 588, 604
Juri fl ap, 476–477
K
Kasabach-Merritt syndrome, 94
keloid collagen fi bers, 7
Kenalog-40, 92
keratinocyte dysplasia, 73
ketamine, 64, 65
Kiesselbach plexus, 271
Killian incision, 259
Kirschner wire (K-wire), 105, 592, 604
Klinefelter syndrome, 557
Klippel-Feil syndromes, 563
Klippel-Trenaunay syndrome, 85, 86
knee amputations, 786
Kodo drummers, 630
KTP laser fi ber, 80f, 85, 88
Kuntscher nail, 635
L
lacrimal function, 294
lacrimal system, routine exploration of, 303
lacuno-canalicular system, 280
lagophthalmos, 461
lambdoid synostosis
in children, 174
in infant, 174
Langer lines, 1
Langerhans cells, 40
laparoscopic hernia, 719
laryngeal mask airway (LMA), 64
laser therapy, 75, 81
lateral circumfl ex femoral artery
perforator-vastus lateralis
(LCFAP-VL) fl ap, 20–23
complications, 23
patient evaluation and selection, 22–23
technique, 23
lateral tarsorrhaphy, 462
latissimus dorsi fl ap, 396–399
LCIS. See lobular carcinoma in situ (LCIS)
LeFort classifi cation, 268
LeFort fractures, 222, 269, 269f.
See maxillary fractures
LeFort I fractures, 228, 270
LeFort I osteotomy, 153, 202, 206
blood supply to maxilla before, 202f
demonstrating maxillary
advancement, 206f
lateral view, 200f
posterior impaction of maxilla/
clockwise rotation, 207f
LeFort II fracture, 228
LeFort III fractures, 228, 269
LeFort injury, 219
Lejour technique, 522
lentigo maligna melanoma (LMM),
70–71, 71f
leukoplakia, 380
LeVasseur-Merril retractor, 203
levator labii superioris muscles, 462
lidocaine, local anesthetics, 63
hirudin, 759
Holt-Oram syndrome, 663
hook fractures, acute, 611
hormone replacement therapy
(HRT), 481
Horner syndrome, 364
HOX genes, 114
human bite wounds, 613, 617
human leukocyte antigen (HLA), 38
hydrocephaly, 122
hydroxyapatite, 27
hydroxyapatite cement, 30, 30f, 377
cranioplasty, 27f
use, 378
hyperglycemia, 780
hypertrophic scars, 7, 8
hypoglossal nerves, 427
hypoglycemia, 92
hypospadias, 739, 741
cripple, 741
I
iliac crest, 274
iliac crest free fl ap, blood supply, 448
Ilizarov method, 752
immunohistochemistry, 43
immunosuppression, 39
immunosuppression minimization/
allograft tolerance, 46
immunosuppressive therapy, 37, 46
impure fractures, 223
in situ melanoma, 71f
index fi nger middle phalanx, pilon
fracture, 605f
inferior gluteal artery perforator (I-GAP)
fl ap, 12, 17
complications, 18–20
donor, 19, 20
patient evaluation and selection, 17
reconstructions, 18
technique, 17–18
inferior orbital rim-buccal
commissure, 182
infl ammatory induration, 73
infl ammatory process, 6
infraorbital nerve (CN V2), 275
infraorbital rim areas, 32
infraorbital rim augmentation, 33
interferon regulatory factor 6 (IRF6)
gene, 125
internal mammary artery (IMA), 13
internal mammary vein (IMV), 13
interphalangeal (IP) joint, 637
intradermal injection, 75f
intramuscular scarring, 13
intraoral cancers, 383
general principles, 380
hematogenous spread, 381
lymphatic spread, 380
unknown primary, 381
MRI scan, 384f
INDEX • 815
lung injury, 717
lymphangiosarcoma, 772
lymphatic channels, 380
lymphatic cysts, 84
lymphatic malformations, 83, 84
lymphatic venous anastomosis, 774, 775f
lymphazerin dye, injection of, 775f
lymphazurin blue dye, 487
lymphedema, 771
chronic, 772f
complications, 776
congenital, 773f
outcomes, 776–778
patient evaluation, 771–773
patient preparation, 773–774
praecox, 84
treatment, 774
algorithm, 773f
lymphatic-venous anastomosis,
774–776
lymphoscintigram, 74f
lymphoscintigraphy, 74
with fi brosis, 772f
M
macrocephaly, 122
macrodactyly, types, 672
macromastia/breast hypertrophy, 517
macroscopic material failure, 280
macular stains, 81
major histocompatibility complex
(MHC), 39
malar prominence, loss, 32f
male breast tissue, 800
male genitalia reconstruction technique
general postoperative care, 741
hypospadias, 739–741
penile reconstruction, 741–744
postoperative care, 744
scrotal reconstruction, 744–745
urethral reconstruction, 741
malignancy, patient’s risk factors, 69
malignant skin lesions, 69
complications, 77
intraoperative sentinel node
identifi cation, 75f
outcomes assessment, 77
staging for melanoma, 77–78
patient evaluation and selection, 69
melanoma
acral lentiginous melanoma
(ALM), 71
lentigo maligna melanoma (LMM),
70–71
nodular melanoma (NM), 70
superfi cial spreading melanoma
(SSM), 69–70
nonmelanoma skin cancer
(NMSC), 71
basal cell carcinoma, 72
Bowen’s disease, 73
dermatofi brosarcoma protuberans
(DFSP), 73
Merkel cell carcinoma (MCC), 73
morpheaform BCC, 73
nodular BCC, 72
pigmented BCC, 73
squamous cell carcinoma, 73
superfi cial BCC, 72
verrucous carcinoma, 73
patient preparation, 73–74
postablative defect, 76f
postablative reconstruction, 76–77
sentinel node, 75f
skin graft reconstruction, 76f
surgical treatments, 74
melanoma, management, 74–75
nonmelanoma skin cancer,
management of, 75–76
malocclusion, 289
mammoplasty, 517
mandible (agnathia), aplasia, 123
mandible condyle fractures, 287
mandible fractures
follow-up, 313
management, 283
mandible reconstruction, 446, 452
mandible, transverse defi ciencies, 203
mandibular angle, 229
mandibular body retractors, 203
mandibular condyle fractures, 297
mandibular defi ciency, 34f
mandibular distraction, 182
mandibular fractures, 279
bridle wire placement, 284f
complications, 289
Ivy loop, 285f
mandible/mechanobiology,
biomechanics of, 279–280
mandibular arch bar, application, 284f
mesial and distal sides of teeth, 285f
outcomes, 290
patient evaluation, 283
patient preparation, 283
patterns of, 280–281
surgical/topological anatomy,
281–283
technique, 283–289
bridle wire placement, 284f
fractures in children, 288
fractures in edentulous patients,
288–289
Ivy loop, 285f
mandible body, fractures of,
286–287
mandibular angle, fractures of, 287
mandibular arch bar, application
of, 284f
mandibular condyle, fractures of,
287–288
symphyseal and parasymphyseal
fractures, 286
teeth in line of fracture, 289
lidocaine/oxymetazoline (Afrin), 258
ligamentous injuries, 221
Linburg-Comstock sign, 585
Lindemann side-cutting burr, 203
lip deformity, 147
lip reconstruction, 335
complications, 342
with large lower lip lesion, 337f
with large lower lip soft tissue defect
secondary, 340f
with large upper lip defect, 339f
with lower lip defect, 338f, 341f
outcome, 342
patient preparation, 336
patient selection, 335–336
technique
lower lip defects between one third
and two thirds, width, 338–340
lower lip defects greater than two
thirds, width, 340–341
lower lip defects less than one third,
width, 337–338
superfi cial defects, 336
upper lip defects, 341–342
vermilion defects, 336–337
lip vermilion, 336
lip, wedge excision, 337
lips, motor innervation, 336
liver grafts, 40
lobular carcinoma in situ (LCIS), 482
high power view, 485f
neoplastic cells, 485
pleomorphic, 486
locally advanced breast cancer (LABC), 488
long face syndrome, 208
lorazepam (Ativan), 62
lower extremity reconstruction, 749
complications, 759
fl ap failure, 760
outcomes, 760
patient evaluation, 749
infection, 750
trauma, 749
tumor, 750
patient preparation, 750
treatment, 750
bone stabilization methods, 751–753
cross-leg fl aps, 756
microvascular soft tissue
reconstruction, 753–754
oncologic wounds, 757–758
orthopedic sepsis, 759
postoperative management, 759
secondary reconstruction, 758
site-specifi c soft tissue reconstruction,
755–756
soft tissue expansion, 756–757
soft tissue reconstruction, 753
timing of, 750–751
vacuum-assisted closure, 757
lower lateral cartilage dermal
suspension, 156f
816 • INDEX
lateral and medial glandular
fl aps, 529f
nipple loss after mastopexy/
augmentation/mastopexy, 537f
patient marking, 527f
patient selection and evaluation,
525–526
poor mastopexy outcomes, 537f
purse-string suture, 530f
regnault classifi cation, 526f
second-degree ptosis and breast
asymmetry, 535f
skin excision pattern, 532f
with third-degree ptosis
and breast asymmetry, 536f
and tuberous breast deformity, 531f
maxillary fractures, 227–228,
298–301
maxillary growth disturbance, 152–153
maxilla’s ability, 265
maxillofrontal, 228
maxillomandibular fi xation, 205
Mayer-Rokitansky-Kuster-Hauser
syndrome, 729
McComb technique, 129
McGowan Stage I, 632
McKusick system, 671
Meckel cartilage, 123, 177
Medawar’s experiment, 46
medial canthal tendon (MCT), 292
Medpor Titan implants, 242
Meigs disease, 84
melanoma
acral lentiginous melanoma
(ALM), 71
anatomic stage groupings, 78t
excision margins, 74t
lentigo maligna melanoma (LMM),
70–71
nodular melanoma (NM), 70
superfi cial spreading melanoma (SSM),
69–70
TNM staging categories, 77t
meningitis, 250
Merkel cell carcinoma (MCC), 73, 75
metacarpal fractures, 586
metacarpal midshaft fractures, 587
metacarpophalangeal (MCP), 583,
691, 706
crease fl ap, 596
joints, 106, 604, 640, 651
metastases, in lymph nodes, 381
methicillin-resistant S. aureus
(MRSA), 619
methylene blue, 247
methylmethacrylate, synthetic
materials, 376
meticulous dissection, 775
meticulous hemostasis, 534
metopic groove, 169
metopic notch, 169
metopic synostosis, 168–170
microcephaly, 122
micrografting, 96
micro-lymphatic surgery, instruments
for, 776f
micro-ophthalmia, 195
microsurgical free fl aps, 377
microsurgical lymph node transfer, 776
microsurgical techniques, 377
microtia, 315
auricular malformation, 178
microvascular anastomosis, 458
microvascular free fl ap
reconstruction, 399
fi bula free fl ap, 408–412
jejunal free fl ap, 400–404
radial forearm free fl ap, 404–406
scapular free fl ap, 406–408
microvascular surgery, 399
microvascular technique, 446
midazolam, 64
midface/maxillary fractures
assessment, 270
airway, 271
hemorrhage, 271
buttresses in sagittal plane, 268f
complications
blindness, 275
cerebrospinal fl uid rhinorrhea, 275
infection, 275
malocclusion, 276
malunion and nonunion, 276
nerve injury, 275–276
soft tissue deformities, 276
symptomatic hardware, 276
craniomaxillofacial surgery
distribution of plate removal, 276f
epidemiology
associated injuries, 265
exposures in midface fracture, 273f
great lines of weakness, 269f
key anatomical structures, 266f
LeFort fractures, 269f
midface buttress anatomy, 267f
midface fractures, 270f
midfacial anatomy
neurovasculature, 268
blood supply, 268
innervation, 268
soft tissues and musculature, 268
midfacial anatomy, buttresses of, 265
horizontal, 267–268
key anatomical structures, 266f
vertical, 267
midfacial fracture, patterns of, 268
LeFort I-IV fracture, 269–270
palatal fractures, 270
physical examination, 271
prima non nocere, 271
radiographic analysis, 272
reconstructive principles, 272
anatomic reduction, 273
bone grafting, 274
mandibular hypoplasia, 123, 179
mandibular reconstruction, 445
anterior arch resection/fi bula free
fl ap, 452f
anterior mandible reconstruction, 453f
complications, 453
diagrammatic representation, 448f
donor sites, comparison, 448t
fi bula free fl ap, planning, 449f
fl ap selection, algorithm, 452f
functional and aesthetic outcome, 454f
hemimandibular defect, 451f
historical perspective, 446
reconstructive goals, 446–447
iliac crest fl ap, design, 450f
outcome, 453–454
patient evaluation, 445
patient preparation, 445–446
preoperative lateral cephalogram, 446f
radial forearm fl ap, 450f
scapular vascular axis, 450f
technique, 447
condyle reconstruction, 450–451
dental rehabilitation, 452–453
fl ap selection, 451–452
free fl ap mandible reconstruction,
447–450
non-free fl ap mandible
reconstruction, 447
nonvascularized bone grafts, 447
prosthetic plates and soft tissue
fl aps, 447
regional osteomusculocutaneous
fl aps, 447
mandibular sagittal split osteotomies, 205f
mandibulomaxillary fi xation (MMF), 202,
221, 272, 283, 296, 308
margin crease distance (MCD), 364
marginal refl ex distance (MRD-1), 364
Marjolin ulcer, 73, 780
mastectomy skin fl ap necrosis, 498
masticatory apparatus, development of, 122
mastoid fascia, 320
mastopexy, 525, 526, 568, 800
ample breast, bilateral mastopexy
operative technique, 527
circumvertical technique, 527–529
concentric technique, 531
wise pattern technique, 529–531
patient preparation, 526–527
areola, marked, 528f
augmentation/mastopexy, 531
augmentation/mastopexy technique,
533–536
patient preparation, 533
breast asymmetry, preoperative
view, 534f
breast augmentation with subglandular
saline, 538f, 539f
complications, 536–539
concentric mastopexy, preoperative
markings, 532f
INDEX • 817
patient evaluation and selection,
255–257
patient preparation, 258
reduction, 310
rhinoplasty instruments, 258
septal fracture, stabilization, 262f
technique
clinical algorithm, 260–261
endoscopic evaluation, 258
nasal fractures, management of,
258–260
nasal reductions, 258
nasal repair, 194
nasendoscopy/videofl uoroscopy, 165
naso-orbitoethmoid (NOE) fracture, 310
classifi cation, 224f
nasoalveolar device, 155f
nasoalveolar molding, 134, 135
nasofrontal ducts, 221
nasofrontal outfl ow tract, 245
nasogastric tube, 401
nasolabial fl ap, 330
nasomaxillary buttresses, 297
naso-orbitalethmoid (NOE) complex,
233, 265, 292
fracture reduction, 310
fractures, 221, 223, 256, 301, 311
Manson classifi cation, 223
fractures, bilateral, 311
immobilization of, 302
lacrimal system, 303
telecanthus, 303
nasopharyngoscopy, 135, 160
nasotracheal intubation, 336
Nd:YAG lasers, 80
neck cancer. See head/neck cancer
neck contractures, 105
neck dissection, 431
necrotic skin, 345
necrotic tissue, debridement of, 289
negative pressure wound therapy
(NPWT), 51–53
dressing, 58
future directions, 59
history and development, 51
patient evaluation and selection, 52–53
patient preparation, 53–55
science and physiology, 51–52
techniques
dermal substitutes, 58–59
dressings on skin grafts, perioperative
use, 55–56
miscellaneous applications, 59
orthopedic wounds, complex, 58
pressure ulcers/chronic wounds,
treatment of, 57
sternal wound infections, 57–58
use of, 57
wound characteristics, 57
neodymium-YAG lasers, 745
neopectoral pocket concept, 568
neophallus, 743
Neo-Synephrine, 258
neovascularization, 332
nerve conduction studies (NCSs), 626
nerve grafting, 632
neural crest cells, 115
neural crest, stabilization, 125
neural tube closure, 114
neurapraxia, 231
neurolysis, 682
neurosurgical dural laceration repair, 246
neurotrophic symptoms, 776
neurovascular bundle, 433
neurovascular pathways, 265
nevoid basal cell syndrome, 71
nipple transposition, 522
nipple-areola complex, 800
nipple-areola necrosis, 523
nipple-areola placement, 521
malposition, 537
nipple-areola reconstruction, 513
nipple-areola, sensory innervation, 518
nipple-sparing mastectomy, uses, 493
nitrous oxide, inhalational agent, 65
nodular melanoma, 70, 70f
NOE. See naso-orbitoethmoid (NOE)
nondisplaced roof fractures, 242
nondisplaced symphysis, 286
nonlifesaving transplants, 37
nonmelanoma skin cancer, 71
basal cell carcinoma, 72
Bowen’s disease, 73
dermatofi brosarcoma protuberans
(DFSP), 73
management of, 75–76
Merkel cell carcinoma (MCC), 73
morpheaform BCC, 73
nodular BCC, 72
pigmented BCC, 73
squamous cell carcinoma, 73
superfi cial BCC, 72
verrucous carcinoma, 73
nonrestorable teeth, 286, 289
nonsurgical management. See conservative
management
nonsurgical therapy, 91–92
nonsyndromic clefts, inheritance, 125
Noordhoff triangular lip fl ap, 129
nose reconstruction, 325
bilobed fl ap, design, 330f
complications, 333
composite skin and cartilage graft, 329f
dorsal nasal fl ap, design, 331f
iliac crest, bone harvested, 328f
nasolabial fl ap, design, 331f
outcomes assessment, 333
paramedian forehead fl ap, uses, 332f
patient evaluation and selection,
325–326
patient preparation, 326–327
rib cage, bone harvested, 328f
saddle-nose deformity secondary, 328f
septum, cartilage harvested, 328f
exposure, 272
coronal and hemicoronal, 273
gingivobuccal sulcus, 272
orbital, 272–273
palalal, 273
mandibulomaxillary fi xation, 273
palatal reconstruction, 274
rigid osteosynthesis, 273–274
sequencing, 272
soft tissue management, 274–275
special considerations, 275
edentulous maxilla, 275
gunshot wounds, 275
midfacial buttresses, 267
Millar repair, 130
Millard rotation, 142
minoxidil therapies, 473
Mobius syndromes, 563
Mohs micrographic surgery, 4, 74, 76, 355
monitored anesthesia care (MAC), 63
Monocryl suture, 536
monofi lament polydioxanone, 347
morbid obesity, 795
moving two-point discrimination (m2PD)
test, 582
mucoceles, sinus malfunction, 251
mucosal defects, 440
mucosal repair, 138
Mueller muscle, 356, 364, 365
muscle spasticity, treatment, 764
muscle testing, manual, 675
muscle wasting, 630
muscle-splitting dissection, 505
musculocutaneous free fl aps, 11
musculocutaneous vessels, 387
Mustarde fl ap, 359
myocutaneous fl aps, 412
myocutaneous latissimus dorsi fl ap
large posterior calf defect
covered, 753f
myofi broblasts, 2
myringotomy tubes, 442
N
Nagata techniques, 322
nail bed trauma, 591
nail irregularities, 616
nasal airway obstruction, 164
nasal alveolar molding (NAM), 127
nasal bone reduction, 258
nasal deformity, 131
nasal fractures, 255, 310, 313
algorithm for management, 259f
bimanual reduction, 260f
complications
post-traumatic nasal deformity,
incidence of, 261–262
data sheet, 257f
inferior septum, submucous
resection, 261f
nasal septum, sagittal view, 256f
818 • INDEX
oral cavity, lymphatic drainage of, 419
oral cavity tumors, maxilla, resection,
424–425
oral squamous cell carcinoma
(OSCC), 419
oral/intravenous clindamycin, 289
orbicularis diastasis, 144
orbital clefts, 194
orbital facial clefts, 195
orbital fractures/deformities, 225,
226, 233
complications, 243
orbital anatomy, 233–234
outcomes, 243–244
patient evaluation, 234–235
deformities, 238–239
general exam, 235–238
imaging, 238
mobility, 238
orbital apex syndrome, 239–240
pupil exam, 238
visual acuity, 238
patient preparation, 240
technique
endoscopic approach, 242–243
medial orbital wall, 242
orbital fl oor fracture, 240–242
orbital roof, 242
orbital trauma, 235
organ procurement organization
(OPO), 41
oronasal fi stulae, 150
oropharynx, epidermoid carcinoma, 380
orotracheal intubation, 293
orthognathic surgery/cephalometric
analysis, 197
basic approaches, to commonly
encountered problems, 205
apertognathia, 206–207
maxillary constriction, 206
short lower face, 208
skeletal class II malocclusion,
205–206
skeletal class III malocclusion, 206
vertical maxillary excess, 208
bilateral sagittal split osteotomy, 203
intraoral vertical ramus osteotomy,
203–204
two-jaw surgery, 204
cleft surgery, 204–205
dental evaluation, 198–200
general principles, 201
genioplasty, 204
history and patient selection, 197–198
LeFort I osteotomy, 201
blood supply to maxilla, 202f
surgically assisted rapid palatal
expansion, 203
outcomes, prognosis, and
complications, 208
pertinent anatomy, 201
treatment plan, developing, 200–201
osteogenesis, 288
osteoinduction, 27
osteoradionecrosis (ORN), 428
osteoseptocutaneous-free fi bular
fl ap, 252
osteotomies, 174
P
palatal clefts, 133
palatal mucosa, 217
palate/velopharyngeal disproportion, 160
palmar skin contracture, 694
panfacial fractures, 291
complications
bleeding, 303
dental injury, 304
facial asymmetry and bony
malposition, 303
infection, 302–303
lacrimal system injury, 303–304
malunion/nonunion, 303
neurologic defi cits, 303
ophthalmologic, 303
skin and soft tissue, 302
facial anatomy, 291–293
horizontal buttresses, 292f
LeFort I fracture, 299f
NOE fracture classifi cation, 295f
outcomes, 304
patient evaluation, 293
diagnostic imaging, 295–296
types (I, II, III), 294
patient preparation, 296
technique, 296
maxillary (LeFort) fractures,
298–301
naso-orbitoethmoid fractures,
301–302
postoperative management, 302
sequencing of surgery, 297–298
zygomaticomaxillary complex
fractures, 298
vertical buttresses, 292f
ZMC complex, 298f
panfacial fracturing, 303
Panorex imaging, 42
paralysis, arm, 675
paralyzed face, reconstruction, 457
complications, 467
eye closure, gold weight loading, 462f
facial musculature, 460t
anatomy of, 458f
facial nerve branching patterns, 459f
facial palsy
etiology of, 460t
treatment algorithm, 461t
fascial/tendinous sling
lower lid support, 463f
outcomes assessment, 467–468
patient evaluation and selection,
457–458
nose reconstruction (Cont.)
techniques
free tissue transfer, 333
mucosal lining, 327
nasal support, 327–329
paramedian forehead fl ap, 330–333
skin coverage, 329–330
total rhinectomy defect, 326f
Notta’s node, 668
NPWT. See negative pressure
wound therapy
O
oblique rectus abdominis myocutaneous
(ORAM) fl ap, 733f
obliteration, 222
obstructive sleep apnea (OSA), 159
OMENS classifi cation, 178
omental fl aps, 715
omentum, 717
oncoplastic breast conserving
surgery, 483
open reduction internal fi xation (ORIF),
297, 307, 605
oral airway obstruction, 84f
oral cancer, 419
complications
osteoradionecrosis (ORN), 428
wound infection, 427–428
lymph node drainage, 420f
mandibulotomy for access, 425f
neck dissection, 427f
oral cavity lesion, partial
alveolectomy, 426f
oral cavity subsites, 420f
oral cavity/lip lesions, AJCC
staging, 422f
oral squamous cell cancer, 421f
outcomes assessment
local recurrence, 428
regional recurrence, 428–429
patient evaluation and selection,
419–421
preoperative evaluation, 421
staging and survival, 421
surgical management, 421
adjuvant therapy, 427
mandibulotomy, 424
modifi ed radical neck dissection
technique, 427
neck dissection, 425–426
oral cavity tumors, maxilla, resection,
424–425
peroral resection, 421–424
supraomohyoid neck dissection
technique, 426–427
tongue lesion, peroral resection
of, 423f
treatment modality
selection, 421
oral cavity cancer, 421, 431
INDEX • 819
lateral circumfl ex femoral artery
perforator-vastus lateralis
(LCFAP-VL) fl ap, 20–23
complications, 23
patient evaluation and selection,
22–23
technique, 23
superfi cial inferior epigastric artery
perforator fl ap, 14
complications, 16
patient evaluation and selection,
14–15
patient preparation, 15
technique, 15–16
superior gluteal artery perforator fl ap
complications, 17
patient evaluation and selection, 16
patient preparation, 16–17
technique, 17
thoracodorsal artery perforator
(TDAP) fl ap
complications, 20
patient evaluation and
selection, 20
technique, 20
perineum/genitalia reconstruction, 727
abdominal wall, appearance, 721f
complications, 745–746
full-thickness skin graft (FTSG), 743f
indications, 729t
introital stenosis and
clitoromegaly, 731f
male genitalia reconstruction technique
general postoperative care, 741
hypospadias, 739–741
penile reconstruction, 741–744
postoperative care, 744
scrotal reconstruction, 744–745
urethral reconstruction, 741
neophallus construction, 742f, 744f
neophallus recipient site, 743f
outcomes, 746
painful recurrent squamous cell vulvar
cancer, 730f
patient evaluation and selection, 727
contraindications, 728–729
indications, 728, 729
patient preparation, 729
pivot points of most loco-regional
fl aps, 729f
split-thickness skin graft, 745f
techniques, 729
anterolateral thigh fl ap, 732
gluteal fold fl ap, 732–737
gluteal thigh fl ap, 732
gracilis fl ap, 732
pudendal thigh (Singapore) fl ap,
730–732
rectus abdominis fl ap, 732
V-Y advancement fl ap, 730
vaginal reconstruction techniques
dilatation/stretching, 737–738
free jejunal fl ap, 739
grafting techniques, 738
intestinal fl ap, 739
locoregional fl aps, 738–739
postoperative care, 739
peroneal artery, 755
Phalen test, 624, 625
pharyngeal arches, 118
pharynx, 116
phenylephrine hydrochloride, 258
philtrum, 193
philtrum reconstruction, 103
Pierre Robin sequence, 133, 164
pigeon chest, 714
pincer nail, 598
place and hold tests, 582
plastic surgeons, 3, 39, 52, 80
plastic surgery, anesthesia, 61, 541
complications, 66
outcomes, 66
patient evaluation and selection,
61–62
patient preparation, 62
technique
airway protection, 64–65
anesthetic, advantages/disadvantages,
65–66
emergence, 65
general anesthesia, 64
induction, 64
local anesthesia, 63
monitored anesthesia care (MAC),
63–64
preparation, 62–63
plate fi xation, 751
pneumatic cavities, 219
pneumocephalus, 230
pneumothorax, 322
Poland syndrome, 564, 714
Poland syndrome, etiology, 564
polidocanol (Asclera), 80
polymerase chain reaction (PCR)
technology, 113
polymethyl methacrylate
(PMMA), 25
cranioplasty, using wire mesh
technique, 29f
frontal cranioplasty, 26f
polymethyl methacrylate–
polyhydroxalmethyl
methacrylate (HTR), 28
polymethylmethacrylate, 29
polysiloxane, 26
porous hydroxyapatite, 27
porous polyethylene, 27f, 31, 247
postbariatric surgery reconstruction, 795
bariatric body contouring, psychologic
considerations, 796
complications, 805
outcomes, 805
patient evaluation, 795–796
patient selection, 796
patient preparation, 458
position of cross-facial nerve graft, 466f
smile, anatomy of, 464f
temporalis muscle transfer, 465f
treatments, 458
brow, 460
cheek and lips, 462
conservative treatment, 458–459
dynamic procedures
microneurovascular muscle
transfer, 463–466
temporalis muscle transfer,
462–463
two-stage free muscle transfer,
466–467
eye, 460–462
static reconstructions, 462
surgical treatment, 459–460
unilateral facial paralysis, 468f
paramedian clefts, 195
Pasteurella multocida infection, 618
pectoralis major fl ap, 388–392
pectoralis major myocutaneous (PMMC)
fl ap, 432
pediatric facial fractures, 305. See facial
fractures, pediatric
facial growth, 306t
growing skull fracture, 313f
mandibular fractures, 309t
mandibulomaxillary fi xation,
alternative forms, 308f
nasal fracture, 310f
naso-orbitoethmoid fracture, 311f
orbital fractures, 312f
classifi cation, 311t
pediatric dentition, 309f
pediatric facial trauma at children’s
hospital, 306t
pediatric facial skeleton, 307
pedicled fi bula osteoseptocutaneous fl ap
arc of rotation, 752f
pedicle/skin island
harvested free fi bular fl ap, 752f
penile shaft, skin defects, 59
penis, squamous cell carcinoma, 734f
Perfecta Vbeam, 80, 95
perforator fl aps, 11, 12
deep inferior epigastric
perforator (DIEP)
complications, 14
patient evaluation and selection,
12–13
patient preparation, 13
technique, 13–14
defi nition of, 11–12
failed implant reconstruction
Baker IV, 19f
I-GAP fl ap, 19f
inferior gluteal artery perforator fl ap
complications, 18–20
patient evaluation and selection, 17
technique, 17–18
820 • INDEX
pudendal thigh (Singapore) fl ap,
730–732
Pulvertaft technique, 654
pyogenic tenosynovitis, 616, 617
R
rabbit ears, 479
radial forearm free fl ap (RFFF), 341, 348,
404–406
radial forearm osteocutaneous fl ap, 449
radial longitudinal defi ciency, 664
radial tunnel syndrome (RTS), 626
radiation induces soft tissue fi brosis, 431
radiation injury, 325
radiation therapy, 428, 499, 502
radical fasciectomy, 694
radiographic evaluation, 245
radiological investigation, intracranial
abnormalities, 167
radiotherapy, 446
radioulnar synostosis, 670
Randall, 128
ranitidine hydrochloride. See Zantac
Raynaud disease, 782
Raynaud symptoms, 625
reconstructive transplantation, 37
chronic rejection factors, 44t
ischemia, 44f
donor hand graft, 42f
emerging insights
chronic rejection, 43–45
cortical reorganization, 45
immunosuppression, reduction/
elimination strategies, 46
evolution of
history, 38–39
immunology, 39–40
experience with
patient and procedural
considerations, 41–42
program establishment and
organization, 40–41
protocol related aspects, 42–43
world experience, 43
hand, partial-thickness injuries, 55f
nasogastric tube, 54f
neural fi ber inputs into sensory cortex,
high-defi nition imaging, 45f
occlusive dressing, applications, 54f
partial-thickness skin loss, 56f
procedures and protocols, 43f
reconstructive microsurgery,
time-tested techniques, 37
skin grafts, 56f
team composition and expertise, 41f
team coordination and
collaboration, 41f
transplanted limb into premotor cortex
neural integration of, 45f
wounds, negative pressure wound
therapy foam dressing, 53f
rectus abdominis fl ap, 732
rectus abdominis musculocutaneous free
fl ap, 437
reduction mammaplasty, 517
complications, 523
outcomes assessment
symptom improvement, 523
patient evaluation and selection, 517
patient selection, 517–518
symptoms, 517
patient preparation, 518
technique
anatomy, 518
operative technique, 520
central/septum-based
approach, 522
drains and antibiotics, 522–523
free nipple grafting, 522
incidental cancer detection, 522
inferior pedicle and wise
pattern, 521
medial/superomedial pedicle, 521
postoperative care, 523
suction-assisted lipectomy, 522
vertical scar reduction,
521–522
pedicle design, 518
skin markings, 519–520
skin resection pattern, 518
miscellaneous skin resection
patterns, 519
vertical scar pattern, 519
wise pattern, 519
Regnault classifi cation, 525
remifentanil, autonomic responses, 65
renal failure
steroid-dependent diabetic patient,
nonhealing wound, 787f
renal transplants, Campath 1H, 46
replantation/revascularization, 635
amputated all four fi ngers, 644f, 645f
amputated left arm, 646f, 647f
complications, 645–647
degloved hand, 637f
dorsal vein repair, 638f
outcomes/assessment, 647
patient evaluation and selection,
635–637
patient preparation, 637
replantation, levels, 636f
technique
amputated part, preparation,
637–638
arterial interposition vein graft,
639–640
digital artery repair, 638–639
digital nerve repair, 639
extensor tendon repair/dorsal vein
repair, 638
fl exor tendon repair, 639
hand replantation, 644–645
major limb replantation, 640–644
postbariatric surgery reconstruction (Cont.)
treatment, 796
abdominal contouring, 797
brachioplasty, 800
gynecomastia, in massive weight loss
patient, 800
lower body lift/buttock contouring,
797–798
mastopexy/upper body
contouring, 800
medial thigh contouring, 798–799
staging and combination procedures,
800–805
posterior deformational plagiocephaly,
treatment of, 175
posterior interosseous nerve (PIN),
583, 624
posterior pharyngeal fl ap (PPF), 159
posterior skin incision, 410
postoperative airway, 138
postoperative nausea and vomiting
(PONV), 64
posttraumatic enophthalmos, 30
premature synchondrosal fusion, 122
pressure sores, 763
complications, 769
outcomes assessment, 769
pathogenesis, 763
patient evaluation and selection, 763–764
patient preparation, 764–765
stages, 764f
technique, 765
debridement, 765
ischial coverage, 765–767
ostectomy, 765
sacral coverage, 767–768
trochanteric coverage, 768–769
pressure ulcers, 57
etiology, 57
treatment of, 57
pressure-specifi ed sensory device
(PSSD), 627
prolonged dural fi stula, 250
prone jack-knife positioning, 765
prophylaxis, 778
propofol, 64, 65
propranolol, cardiologic, 92
proximal interphalangeal (PIP) joints, 105,
585, 596, 604, 654, 691
volar dislocations, 590
proximal phalanx, spiral oblique
fracture, 605f
pseudogynecomastia, 800
pterygomaxillary buttress, 267
pterygomaxillary dysjunction, 227
ptosis
breast, 525
degree of, 527
etiology, 364
glandular, 525
repair, 355–368 (See eyelid
reconstruction)
INDEX • 821
scaphocephaly. See sagittal synostosis
scaphoid, blood supply, 609
scaphoid distal pole excision, 610
scaphoid fractures, 609
scapular fl ap, disadvantages, 450
scapular free fl ap, 406–408
scar contracture, 109
scar tissue encapsulating,
formation, 552
Scarpa’s fascia layer, 724
sclerotherapy, 79
screw fi xation, 32f
implant to skeleton and obliterates
gaps, 32f
secondary double S-GAP reconstruction,
preoperative view, 18f
secondary muscle deformity,
prevention, 144
secondary nasal deformity, 261
sella-nasion-subspinale (SNA), 198
sella-nasionsupramentale (SNB), 198
Semmes-Weinstein testing, 626
sensory examination, 675
sensory motor, 45, 680
sensory nerve action potentials (SNAPs),
627, 676
sentinel lymph node (SLN), 74
sentinel node biopsy (SNB), 75, 381
seroma formation, 77
seromas, 805
severe palatal fractures, 270
SGA. See superior gluteal artery (SGA)
S-GAP. See superior gluteal artery
perforator (S-GAP)
silicone. See polysiloxane
silicone chin implants, 26f
silicone gel implants, gravity
effects, 568
silicone occlusion, 7
silicone rods, 366
sinus defunctionalization, 248
sinus fractures, frontal, 221
sinuses. See pneumatic cavities
sinusoidal incision, 272
skin antigenicity, 40
skin fl aps, 20
transposition, 143
skin grafts, 38, 325, 327, 373
foot, 2f
reconstruction, 76, 76f
techniques, 745
skin incision, 397
skin laxity, 797
skin loss, full-thickness, 59
skin markings, 521
skin tensions, 1
skin/bladder mucosa, loco-regional
fl aps of, 741
skin-edge necrosis, 5
skin-muscle fl ap, 225
skin-sparing mastectomy, 483
skull asymmetries, 177
skull base surgery
anterior cranial fossa, 214f–215f
complications, 217
extracranial approaches, 211f
transfacial approaches, 216f
frontogaleal and pericranial fl aps, 213f
intracranial approaches, 211f, 212f
outcomes assessment, 218
patient evaluation and selection, 209
patient preparation, 209–210
region of tumor sites, 210f
surgical technique
combined surgical approaches, 217
extracranial approaches (Levels
IV-VI), 213–217
intracranial approaches (levels I–III),
210–213
transfacial approaches, classifi cation
of, 210
skull, kyphotic shape, 210
skull model, left frontal defect, 28f
3D CT data, 28f
sleeve anastomosis, 775f
smokers, fl ap necrosis, 525
Snellen chart, 219
Snoopy deformity, 570
sodium tetradecyl sulfate, 80
speech abnormalities, 217
speech impairments, 138
speech/airway stability, 166
spider veins, large, 89
split palate, 270
split-thickness skin graft (STSG), 102,
330, 345, 434, 751f
squamous cell carcinoma (SCC), 71
SSM. See superfi cial spreading
melanoma (SSM)
Staphylococcus aureus, 317
Staphylococcus epidermidis, 547
static two-point discrimination
(s2PD), 626
stealth coronal incision, fronto-orbital
reconstruction, 170
Steindler fl exorplasty, 686
stereolithographic (SL) biomodels, 28
sterile matrix graft, 598
sterile technique, 73, 101
sternocleidomastoid fl ap, 387–388
sternocleidomastoid (SCM) muscle,
387, 680
steroids, perioperative, 174
steroids/beta-blockers, congenital vascular
malformations, 80
stork bite, 81
Sturge-Weber syndrome, 80, 81f
subungual melanoma, 72f
suction-assisted lipectomy, 522
sun exposure, lifetime, 69
superfi cial inferior epigastric artery
(SIEA) fl ap, 12, 15, 16, 503, 565
breast reconstruction, preoperative
view, 16f
multiple fi nger replantations, 640
osteosynthesis, 638
stump, preparation of, 638
thumb replantation, 640
thumb amputated, 641f, 642f, 643f
vein graft harvesting, volar distal
forearm, 639f
respiratory function, 326
retrobulbar hematoma, 243
revascularization, 25
rhinoplasty, defi nitive, 156
rib crest, 274
rib fractures, 676
rigid fi xation techniques, 31
Ring–Adair–Elwin (RAE) endotracheal
tube, 127, 201
Risdon incision, 287
rodent ulcer, 72
Rolando fractures, 609
Rosenbaum pocket chart, 238
Rowe disimpaction forceps, 202,
205, 273
S
sagittal synostosis, 170
saline wet-to-moist dressing, 57
scalp
layers, 372
lymphatic system, 371
muscles, motor innervation, 370
neurovascular anatomy, 370, 370f
reconstruction, 369–379 (See also
scalp/calvarial/forehead
reconstruction)
scalp/calvarial/forehead reconstruction
CN VII, schematic drawing, 371f
complications, 377–378
cranium, 371–372
innervation, 369–371
intraoperative photographs, 374f,
375f, 376f
lymphatic system, 371
Mohs micrographic surgery, 374f
neurovascular anatomy, schematic
drawing, 370f
outcomes, 378
patient evaluation, 372
patient preparation, 372
scalp/forehead muscles, 371
technique
reconstructive strategies, 372
cranial vault reconstruction,
375–377
cutis aplasia congenita, 377
fl ap reconstruction, 377
galea, 373
healing by secondary intention, 373
plastic surgeons, 372
skin grafting, 373–374
tissue expansion, 375
vascular supply, 369
822 • INDEX
median nerve palsy, 655
abductor digiti minimi (ADM)
transfer for opposition, 656
extensor indicis proprius transfer, for
thumb opposition, 655
FDS IV tendon, 655
palmaris longus transfer for
opposition, 655–656
rehabilitation, 656
muscle physiology
blix curve, 651
excursion, 651
muscle fi ber geometry, 651
muscle force, 651
work, 651
principles of, 651–652
radial nerve palsy
brand tendon transfer, 653–654
jones tendon transfer, 654
low, 652–653
modifi ed boyes, 654
rehabilitation after tendon
transfers, 654
ulnar nerve palsy, 657–661
clawing, correction, 657
ECRB, brand, 658
ECRB to adductor pollicis, 659
FDS IV to adductor pollicis, 660
FDS IV transfer, 657–658
low, 657
power pinch, reconstruction, 659
reconstruct power pinch, 660
reestablish function of FDP IV and V,
660–661
rehabilitation, 658–660
small fi nger abduction, 661
Zancolli lasso procedure, 658
tennison repair, 128
Tenon capsule, 233
tensor fascia lata (TFL) musculocutaneous
fl ap, 768
Tessier classifi cation, 191
theoretic growth disruption, 307
thin nasal mucosa anteriorly, 136
third cranial nerve palsy, 364
thoracic artery, internal, 518
thoracoacromial vessels, 391
thoracodorsal artery perforator (TDAP)
fl ap, 20
complications, 20
patient evaluation and selection, 20
technique, 20
thumb hypoplasia, 664
thumb IP joint, 589
tibial fracture, fi xed with plate, 22f
tibial tuberosity, 246
Tinel sign, 466, 675
tissue adhesives, 4
tissue rearrangement, 6
titanium embedded polyethylene, 242
titanium microplates, 328
titanium vs. resorbable osteosynthesis, 231
TMJ. See temporomandibular joint (TMJ)
TNM system. See tumor, node, metastasis
(TNM) system
tongue base defects, 440
tongue fl ap, 385
tongue function restoration, 437
tongue hypertrophy, 84f
tourniquet control, 592
Townes’ view, 296
TRAC pad, 54
TRAM fl ap. See transverse rectus
abdominis myocutaneous
(TRAM) fl ap
transconjunctival retroseptal incision, 30
transforming growth factor beta
(TGF-b), 2
transnasal wiring, 302
transposition fl aps, use of, 9
transverse carpal ligament (TCL), 622
transverse platysma fl ap, 386
transverse rectus abdominis myocutaneous
(TRAM) fl ap, 12, 501, 565
breast reconstruction, 505
skin island, 503, 504
upper edge of, 505
trapdoor fractures, 311
trapezius fl ap, 392–396
trapezius muscle, 427
trapezius myocutaneous fl ap, 392
trapezoid fractures, 611
trigonocephaly. See metopic synostosis
Tripier fl ap, 356
trochanteric pressure sore coverage, tensor
fasciae lata perforator fl ap, 769f
trochanteric pressure sores, 768
trumpet nail. See pincer nail
tuberous breast deformity, 560
tumor cells, 380
tumor, node, metastasis (TNM) system, 421
classifi cation, 78
tumor resection, 211, 213
Turner syndrome, 123
U
ulnar collateral ligament damage, 589
ulnar defi ciencies, 663
ulnar motor/sensory techniques, 628
ulnar nerve, 623
Unna boot dressing, 792
upper extremities, soft tissue
reconstruction, 591
anatomy, 597
secondary nail deformities/
complications
pincer nail, 598
split nail, 598
thumb, 597
fi rst dorsal metacarpal artery
fl ap, 598
littler method, 598
moberg advancement fl ap, 598
superfi cial inferior epigastric artery
perforator fl ap, 14
complications, 16
patient evaluation and selection,
14–15
patient preparation, 15
technique, 15–16
superfi cial musculoaponeurotic system
(SMAS), 343
superfi cial radial nerve (SRN), 624
distal sensory symptoms, 632
superfi cial spreading melanoma (SSM),
69–70
ABCD criteria, 70f
superior gluteal artery (SGA), 511, 565
superior gluteal artery perforator
(S-GAP), 12
complications, 17
donor, 19, 20
patient evaluation and selection, 16
patient preparation, 16–17
procedure, 17
technique, 17
surgically assisted rapid palatal
expansion (SARPE)
technique, 203, 206
Surveillance, Epidemiology, and End
Results (SEER) report, 419
swollen extremity, 776
T
T cell, 42
tamoxifen, 489
tarsal conjunctival Mullerectomy, 367
TDAP fl ap. See thoracodorsal artery
perforator (TDAP) fl ap
temporal bone, zygomatic process, 288
temporalis muscle fl aps, advantages
of, 463
temporalis muscle transfer, 461, 462
temporomandibular joint (TMJ), 291
ankylosis, 289, 309, 312
capsule, 283
dysfunction, 198, 289
symptoms of, 197
temporoparietal fascia (TPF) fl ap, 319
tendon transfers, 651
Blix curve integrates, brand
modifi cation of, 652f
Brand tendon transfer, 659f
complications, 661
extensor carpi radialis brevis (ECRB),
653f, 659f
extensor indicis proprius (EIP), 656f
extensor pollicis longus tendon, 653f
fl exor carpi radialis tendon, 654f
fl exor digitorum superfi cialis,
655f, 658f
free muscle transfers, 706–707
high median nerve palsy, 657
low ulnar nerve palsy, 660f
INDEX • 823
outcomes, 632–633
patient preparation
electrodiagnostic studies, 626–627
median nerve testing, 627
radial nerve testing, 628
ulnar nerve testing, 627–628
patient selection
median nerve compression, 624–625
radial nerve compression, 626
ulnar nerve compression, 625
technique
posterior interosseous nerve, 632
pronator syndrome, 628–629
radial nerve, 630–632
ulnar nerve, 630
V
vaccinations, attenuated virus, 92
vacuum assisted closure (VAC)
device, 51–54, 56, 57, 59, 102,
109, 753, 788
therapy, 713, 717
vaginal agenesis, 738
vaginal reconstruction techniques,
729, 739
dilatation/stretching, 737–738
free jejunal fl ap, 739
grafting techniques, 738
intestinal fl ap, 739
locoregional fl aps, 738–739
postoperative care, 739
Valsalva maneuver, 217
Van Der Woude syndrome, 133
Van Nuys Prognostic Index, 483
varicose veins, of extremities, 83
vascular endothelial growth factor, 93
vascular malformations, 79
capillary vascular, 81f
upper lip hypertrophy, 82f
cheek, pyogenic granuloma of, 88f
congenital lymphatic malformation, 86f
disseminated venous malformations, 84f
Klippel-Trenaunay syndrome, 86f
knee, congenital venous
malformation, 85f
massive lower lip hypertrophy, 83f
massive tongue hypertrophy, 84f
middle sacral/internal iliac arteries,
arteriovenous malformations, 87f
neck/chest, port wine stains, 81f
patient evaluation and selection, 79
nonsurgical therapy, 79–80
types of vessels, 79
patient preparation
laser considerations, 80
percutaneous deep laser
photocoagulation, 80f
Sturge-Weber syndrome, 81f
surgical treatment
angiofi bromas, 88
arteriovenous malformations, 86–87
capillary vascular malformation,
80–81
Klippel-Trenaunay syndrome, 85–86
lymphatic/venolymphatic
malformations, 83–85
pyogenic granulomas, 88
telangiectasias, spider angiomas,
cherry angiomas, and spider
veins, 88–89
venous malformations, 81–83
treatment, complications, 89
tuberous sclerosis, angiofi bromas, 88f
vastus lateralis muscle fl ap, 734f
Veau-Wardill-Kilner repair, 136
Vecchietti method, 737
VEGFR3 tyrosine kinase receptor
defi ciency, 771
velopharyngeal dysfunction (VPD), 159
surgery, risks of, 162
velopharyngeal insuffi ciency, 159, 179
complications
furlow palatoplasty, 163
posterior pharyngeal fl ap, 164–165
sphincter pharyngoplasty, 163–164
furlow double-opposing
z-palatoplasty, 163f
nasopharyngoscopy at rest, 161f
outcomes assessment, 165–166
patient evaluation, 159–160
patient preparation, 162
anesthesia, 162
equipment and positioning, 162
informed consent, 162
posterior pharyngeal fl ap, 165f
preoperative magnetic resonance
angiogram (MRA), 160f
procedure selection, 160–162
sphincter pharyngoplasty, 164f
technique
furlow double-opposing
z-palatoplasty, 162
posterior pharyngeal fl ap, 162–163
sphincter pharyngoplasty, 162
videofl uoroscopy during rest, 161f
velopharyngeal port, 159
velopharynx, imaging of, 160
venous congestion, 645, 754
venous insuffi ciency, 645
venous outfl ow obstruction, 759
venous stasis ulcers, 782
venous thrombosis prevention, 797
vermilion
defi ciencies, 144
in bilateral cleft secondary
deformities, 145
reconstruction, 341
vertical medial thigh plasty, 799f
vertical scar reduction techniques, 521
videofl uoroscopy, 135
Virchow’s law, 167
visceral injury, 723
vitallium, 27
tumors
DIP ganglion/mucous cyst, 599
glomus, 598–599
subungual pigmented lesions,
599–600
anterior interosseous nerve
compression, 622f
anterolateral approach to PIN
decompression, 623f
anteromedial approach to median
nerve, 629f
chronic paronychia, treatment
for, 593f
DIP ganglion, 600f
dorsal preoperative photograph
of attempted index fi nger
abduction, 631f
germinal matrix, nail production
begins, 592f
glomus tumor, 600f
lateral and transverse incisions, 594f
local fl aps for thumb
reconstruction, 597f
MCP crease fl ap, 596f
mini-incision approach, 630f
nail bed avulsions, epopnychial
avulsion accounts, 595f
nail streak, 600f
paronychia/felon, herpetic
whitlow, 594f
patient evaluation and selection, 591
patient preparation, 591–592
pincer nail/trumpet nail
deformity, 599f
techniques
infections, 592
felons, 593
paronychia, 592–593
trauma, 593
burns, 595
healing by secondary intention,
593–594
microsurgical reconstruction, 595
nail bed avulsion, 595
nail bed, free graft, 595
nail bed laceration, 594
salvage of all usable parts,
594–595
V-Y advancement
Atasoy-Kleinert fl ap, 595–596
cross-fi nger fl ap, 596
Kutler V-Y Flap, 596
reversed homodigital fl ap,
596–597
thenar fl ap, 596
upper extremity, compressive
neuropathies
complications, 633
nerve anatomy
median nerve, 621–623
radial nerve, 624
ulnar nerve, 623–624
824 • INDEX
volar cortical fractures, 610
volar interossei muscles, 586
von Langenbeck palatoplasty, 139
V-Y advancement fl ap, 730
V-Y gluteus maximus fl ap, 768f
V-Y hamstring fl ap, 767
for ischial pressure sore coverage, 767f
W
Wallerian degeneration, 676
Walsham forceps, 258
Wassel classifi cation, 670
Weber-Ferguson incision, 213
whistle deformity, 142
white-eyed blowout fracture, 239
wire fi xation, 301
wire mesh technique, polymethyl
methacrylate cranioplasty, 29f
wound area, measuring, 782f
wound biopsies, 764
wound dehiscence, 138, 427
wound healing, complications
fi broproliferative scars, treatment, 7
keloids and hypertrophic scarring, 6–7
nonsurgical management, 7
cryosurgery, 8
future treatments, 8
intralesional steroid injections, 7
lasers, 8
occlusive dressings, 7
pressure dressings, 8
radiation, 7–8
surgical management, 8–9
wound healing, principles
biology of
contraction, 2–3
epithelization, 2
infl ammation, 2
skin, biomechanical properties
skin tensions, 1–2
tensile strength, 2
wound infections, 769
wound instillation therapy, 59
wound, metal probe, 783f
wound, nonhealing
renal failure, steroid-dependent diabetic
patient, 787f
wound repair
avoiding tension, 5–6
chest lesion, 5f
goals of, 3
patient evaluation and selection, 3
patient preparation, 3–4
rapid epithelization, 6
reducing infl ammation, 6
right ear keloid, recurrence of, 8f
wound closure, techniques, 4–5
wound-edge retraction, 5
wounds
chronic, treatment of, 57
chronicity, 780f
negative pressure wound therapy foam
dressing, 53f
w-plasty, 9
wrist fractures. See hand/wrist fractures
W-shaped medial canthal skin incision, 242
Wuchereria bancrofti, 772
Wuringer horizontal septum, 518
X
xeroform gauze/adaptic, 56
Z
Zancolli modifi cation procedure, 658
Zantac (ranitidine hydrochloride), 92
zig-zag Bruner-type incisions, 696, 697
ZMC. See zygomaticomaxillary
complex (ZMC)
zone of polarizing activity (ZPA), 663
z-plasty, 9
zygomatic arch, 228, 268, 371, 462
zygomatic buttress, 205
zygomaticofrontal suture, 311
zygomaticomaxillary buttresses, 267,
297, 298
zygomaticomaxillary complex
(ZMC), 233
fractures, 226, 269, 298, 311
numerous surgical approaches, 298
zygomaticospehnoid suture, 298