Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Classification schemes are not widely used in clinical practice; however, knowledge of basic systems may
facilitate procedure choices and discussions. The first classification of the upper arm deformity, described
by Teimourian and Malekzadeh in 1998, divided upper arm findings into four categories 8 :
Group 1: Patients with minimal to moderate subcutaneous fat and minimal skin laxity
Group 2: Patients with generalized accumulation of subcutaneous fat and moderate skin laxity. The
authors suggested management of these patients with liposuction, with the possible addition of a
small axillary skin excision
Group 3: Patients with excess fat and extensive skin laxity requiring combined liposuction and direct
soft-tissue excision
Group 4: Patients with minimal excess adiposity but significant skin laxity, requiring brachioplasty
without adjunctive liposuction
Later classification systems built on and refined this concept. In addition to the degree of skin and fat
excess, the algorithmic system introduced by Appelt et al. in 2006 added the variable of location of skin
excess 9 :
Type I: Patients with relative excess of adipose tissue but good skin quality and tone, for whom
liposuction alone was recommended
Type II: Patients with minimal to moderate adipose tissue and moderate skin laxity. Excisional
brachioplasty techniques were endorsed for this patient population, with a further subdivision into
type IIA, IIB, and IIC based on the location of skin excess and the related skin excision pattern
Type III: Patients with both significant lipodystrophy and redundant skin laxity fall into three
categories:
Continued weight loss prior to surgery
Staged treatment with initial liposuction followed by excisional brachioplasty
Combined liposuction-excisional brachioplasty
Type III patients were again subdivided based on location of skin excess, which determines the skin
excision pattern for any brachioplasty procedure performed.
Another widely accepted classification system described by El Khatib appeared in the literature the
following year with five stages of brachial ptosis and management according to adipose deposits and skin
laxity. 10
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Related Anatomy
The fascial systems of the upper arms provide important landmarks for the surgeon performing
liposuction or excisional contouring procedures. The superficial fascial system is found between the
superficial and deep layers of subcutaneous fat. Loosening of this layer with age or significant weight
fluctuations can contribute to upper arm ptosis; as such, some authors advocate plication of this layer
during the closing portion of the procedure. 11 The deep fascial system envelops the musculature, and all
major neurovascular structures of the arm lie deep to this layer. Care should be taken to avoid violation
of this layer during all aspects of the procedure.
Two sensory nerves travel superficial to the deep fascial layer and are thus at risk during brachioplasty
procedures: the medial brachial cutaneous nerve and the medial antebrachial cutaneous (MABC) nerve
(Figure 66.2). Damage to these nerves results in sensory dysfunction, a well-recognized possible
complication of this procedure. Both nerves arise from the medial cord of the brachial plexus. The MABC
nerve, which is the more frequently involved of the two, pierces the deep fascia an average of 14 cm
proximal to the medial epicondyle and travels with the basilic vein in the superficial plane of the distal
half to third of the upper arm. To prevent damage to these sensory nerves, at least 1 cm of fat should be
left on the deep brachial fascia of the upper arm if possible. Adjunctive liposuction can also be employed
to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma
formation. To prevent ulnar nerve injury, liposuction access incisions should be avoided at the
posteromedial elbow, and caution should be exercised with the liposuction cannula tip in this same
region.
FIGURE 66.2 Upper arm anatomy. During upper arm contouring, knowledge of the relevant anatomy is essential. The shaded
areas highlight the axilla and posteromedial elbow, which are approached cautiously secondary to the brachial plexus in the
axilla and the superficial path of the ulnar nerve distally. The medial antebrachial cutaneous nerve travels with the basilic vein
and should be preserved.
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Preoperative Evaluation, Planning, and Marking
A thorough history and physical examination must be conducted at the time of the initial evaluation, with
special attention paid to weight loss/gain, stability of current weight, tobacco use, medical comorbidities,
and nutritional status. Physical examination should include full motor and sensory examinations of the
bilateral upper extremities, in addition to assessment of skin quality and tone. Evaluation of the degree of
excess skin and adipose tissue forms the basis for operative planning. Importantly, patients must be
willing to accept potentially unfavorable scarring in exchange for improved contour.
To best determine the degree of excess skin, fat, and ptosis, the patient is asked to stand with the shoulder
abducted to 90° and the elbow flexed at 90°. Details of marking and surgical technique specific to each
approach are highlighted in the relevant sections.
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Liposuction
For patients with minimal skin laxity and a mild to moderate amount of adipose deposits in the upper
extremity, liposuction can be performed as a stand-alone technique for upper extremity recontouring. It
can also be performed as a staged procedure or as an adjunct to traditional excisional brachioplasty
procedures. Traditional, mechanical, and/or ultrasound-assisted liposuction may be employed according
to the surgeon’s preference.
The patient should stand in the position described above, with shoulders abducted and elbows flexed.
Pockets of adipose tissue are marked out and access incisions planned by avoiding areas that must be
treated with caution while performing liposuction: the axilla, to avoid damage to branches of the brachial
plexus, and the posteromedial elbow, to avoid damage to the ulnar nerve (see Figure 66.2).
The operation is performed under local, monitored, or general anesthesia with the patient in the supine
position. Arms should be supported on single arm boards, abducted to approximately 80°. Following
standard procedures for prepping and draping, tumescent fluid is infiltrated into each arm prior to
suction lipectomy. Care should be taken to remain above the deep brachial fascia with the liposuction
cannula, leaving a layer of fat over this deep fascial layer to preserve lymphatics and avoid significant
contour irregularities. Long, uniform strokes are also recommended to improve outcomes. Liposuction to
the bicipital groove is avoided to minimize contour irregularity in this region, which is known
anatomically to be relatively devoid of fat. 7,9,12
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Minibrachioplasty (Limited Medial Incision Brachioplasty)
For patients with good skin quality but a moderate excess of skin and adipose tissue limited to the
proximal one-half to one-third of the upper arm, the minibrachioplasty is a reasonable option to consider.
This procedure has little to no benefit for the MWL patient.
Preoperative planning should begin with the patient standing in the upright position, with arms resting
at his or her sides. The anterior and posterior borders of the axillary skin crease are marked, signaling the
boundaries of the planned incision (Figure 66.3). The patient is then asked to stand with the arm raised,
shoulder abducted, and elbow flexed. The two points are connected along the axillary fold; this line now
defines the planned medial incision. A pinch test is performed to determine the extent of resection, which
is generally limited to 3 to 5 cm at its widest point. A vertical dart can be added as needed to correct
residual horizontal excess. Hatch marks are placed to assist with realignment at the conclusion of the
procedure.
FIGURE 66.3 Minibrachioplasty. For patients with small degrees of skin laxity, with or without excess adiposity, an elliptical
incision can be designed in the axilla for skin tightening. This incision may contain a vertical dart (dashed lines) for dog-ear
removal or to excise more redundant upper arm skin.
The procedure is performed under local, monitored, or general anesthesia. Setup and liposuction should
proceed as described in the previous section. The axillary elliptical incisions are made using a scalpel, and
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then electrocautery is used to raise the tissue in a subcutaneous plane. The medial and lateral skin flaps
may be undermined to facilitate closure, but this is typically not necessary. A transverse extension at the
midpoint of the incision can be designed to correct a dog-ear or correct for ongoing skin laxity. 7,13
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Extended Brachioplasty
An extended brachioplasty is the procedure of choice for patients with significant skin laxity that cannot
be corrected by the methods described earlier. Most MWL patients require this technique if they desire
improved arm contour. The superior incision is marked approximately one fingerbreadth above the
bicipital groove (Figure 66.4). The inferior incision is then determined with the assistance of a pinch test,
often resulting in mark placement just posterior to the inferior-most extent of hanging skin. The final
inferior mark is rechecked after skin undermining. An extension to the chest wall is often added and is
known as an L-brachioplasty with the superior L-point in or near the deltopectoral groove along the
anterior axillary line. The distal extension is planned based on the expected amount of tissue resection
and confirmed with a pinch test. Care is taken to avoid overresection and prevent breast lateralization.
FIGURE 66.4 Markings for upper body lift. This patient had massive weight loss and desired an improvement in her contour. A.
Markings for Wise pattern mastopexy. B. Markings for Wise pattern mastopexy and brachioplasty. C. Side view showing
continuity of breast and back markings. D. Bra-line excision of axilla and back.
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The operation is performed under monitored or general anesthesia with the patient in the supine
position. Arms should be supported on single arm boards, abducted to approximately 80°. Following
standard procedures for prepping and draping, tumescent fluid is infiltrated into each arm if liposuction
is going to be used to facilitate the dissection. The amount of tumescent fluid should be minimized, so as
to avoid large-volume swelling that may ultimately inhibit the degree of resection. Liposuction is then
performed through access incisions placed within the planned area of resection. Liposuction beyond the
borders of the planned resection is intentionally limited, as aggressive liposuction of these areas may
compromise the remaining soft tissue and lead to postprocedure skin loosening when swelling resolves.
The anterior incision is then made, and dissection of the skin flap from anterior to posterior is performed
in the honeycomb plane that has been defined by the previous liposuction (Figure 66.5A). Intermittent
pinch tests are performed to ensure the accuracy of the preoperative markings and the ability to close the
skin once the inferior incision has been made. The final excision of the skin flap and resultant contour are
guided by tailor tacking and either segmental resection or alternatively by committing to the entire
inferior incision at once (Figure 66.5B). The longitudinal resection of the upper arm tissue is achieved
first, and then adjustments are made to the axillary/chest wall component as needed. Three-layer closure
of the wound is also performed using absorbable sutures in a sequential fashion, over a drain (Figure
66.5C). Reapproximation of the superficial fascial system importantly helps maintain contour and
prevents scar puckering. 14
FIGURE 66.5 Extended brachioplasty technique. A. Liposuction facilitates the dissection plane and leaves fat down on the
deep fascia, thus helping to preserve nerves and lymphatics. B. A segmental excision maximizes skin excision without risking
the ability to close. C. The incisions are closed in three layers to avoid indentation and scar puckering.
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Postoperative Management, Outcomes, and Complications
All patients should be placed into compressive dressings at the end of the procedure, regardless of the
selected technique. These compression garments should be worn day and night for at least 6 weeks
postoperatively. Drains placed for brachioplasty procedures offload stress on the incisions early and can
be removed at the first postoperative visit.
Recent studies have demonstrated intact sensory and lymphatic function following brachioplasty
employing liposuction for atraumatic dissection of tissue planes. 15 This technique helps preserve the
layer of fat above the deep brachial fascia harboring the sensory nerves and lymphatics.
Reported complications of the procedure include seroma, hematoma, infection, wound breakdown, slight
asymmetries between sides, paresthesias, lymphedema, and unsightly scarring. Risk factors that may
increase the chance of overall complications, hematoma, or infection include male gender, BMI >30, and
combined procedures. 16 Thoughtful preoperative discussions with patients regarding these risks are
critical to ensuring a positive outcome. Patients must be willing to accept these risks to achieve improved
contour with decreased volume of the upper arms.
Ongoing debate remains over optimal scar placement. An anterior scar placed just below the bicipital
groove of the upper arm is well hidden on both anterior and posterior views with the arms at the side. If
the incision is instead placed posteriorly, it will be visible when the patient has his or her arm by the side,
but it may have the advantage of avoiding the arm sensory nerves with tissue removal. For thick or heavy
scarring, which may occur despite optimal scar placement and technique, regular application of silicone
sheeting or scar massage may improve scar appearance. 17
With careful planning, thorough preoperative discussions, and careful execution, brachioplasty
procedures can achieve significant cosmetic and functional improvements for patients. Risk profiles
should be carefully considered prior to proceeding; however, with the right patient and operative
technique, satisfactory outcomes should be obtainable (Figure 66.6).
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FIGURE 66.6 Brachioplasty result. The scar is located at the level of the bicipital groove and fades over time.
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Breast Contouring
Related Anatomy
The medial and lateral borders of the breast are defined by the sternocostal junction and the midaxillary
line, respectively. The second intercostal space marks the superior boundary. The inframammary fold
(IMF) delineates the inferior border of the breast and is formed by the fusion of the deep and superficial
fascia with the dermis. Composed of multiple interconnected subunits, the breast is made of mammary
glands and associated adipose tissue, which increases as the glandular component subsides after lactation
or during menopause. Each mammary gland consists of a host of secretory lobules, which converge to
form lactiferous ducts that drain to the nipple. Layers of deep and superficial fascia support the soft
tissues of the breast, as do the suspensory Cooper ligaments. Aging and stretch due to weight loss/gain or
breastfeeding can lead to attenuation of these structures, contributing to breast ptosis.
Blood supply to the breast must be vigilantly maintained during all contouring procedures. The
subdermal plexus provides blood supply to the skin and nipple-areolar complex (NAC). The parenchyma
is supported by vascular inflow from perforating branches of the internal mammary artery, the lateral
thoracic artery, the thoracodorsal and thoracoacromial arteries, and multiple intercostal perforators.
Innervation of the breast is derived from anteromedial and anterolateral branches of the thoracic
intercostal nerves, with the fourth intercostal nerve considered the major contributor to the NAC.
Lymphatic drainage occurs via superficial and deep lymphatic drainage systems. The subareolar and
subdermal regions drain via the superficial lymphatic system to the axillary basin. The deep lymphatic
system drains to the axillary nodes as well, but also exhibits connections with a perforating system that
drains to the internal mammary nodes. Other node fields that directly drain the breast include the
interpectoral, infraclavicular, supraclavicular, and intercostal nodal basins. 18,19
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Preoperative Evaluation, Planning, and Marking
The loss of volume and attenuation of soft tissue, skin, and ligamentous support associated with MWL
results in deflated, ptotic breasts that little resemble the ideal, youthful breast (see Figure 66.1). Given the
resultant superior pole deficiency, lack of lateral breast definition, and associated contour deformities of
the axilla or posterior trunk, the MWL patient provides the plastic surgeon with a unique set of
challenges when attempting to improve breast contour and volume, as traditional techniques may not
sufficiently address these concerns. 20 Additionally, the nipple position in MWL patients is frequently
located too medial and the IMF too inferior compared with normal breast anatomy, presenting yet other
factors to be considered in surgical design and planning.
The breast technique employed largely depends on the current breast volume and desired breast volume
20 (Figure 66.7). Breast ptosis is nearly universal in the weight loss population. If the patient has large
breasts and desires smaller breasts, a reduction mammoplasty is performed. If the patient desires to stay
the same size, a mastopexy or augmentation mastopexy is offered depending upon the overall size and
shape goals. For the patient desiring an increase in breast size, a breast augmentation alone rarely is
enough to correct the loose skin and ptosis. Instead, an augmentation mastopexy with implants or
autologous tissue is most often chosen. The following breast procedures are covered in separate chapters,
but challenges and techniques specific to the MWL population are emphasized in the following sections.
As with all patients planned to undergo breast surgery, history of personal or family breast cancer, prior
breast procedures, and up-to-date mammography results must be obtained as part of the preoperative
workup.
FIGURE 66.7 Breast contouring. Options for breast contouring most commonly involve a mastopexy with shaping sutures. A
mastopexy with autologous augmentation using an intercostal artery perforator flap can be considered. Augmentation
mastopexy is performed in one or two stages. A. For a one stage approach, access through a vertical incision preserves lower
pole breast support. B. Once the implant is placed, the skin is tailor-tacked around the implant for a circumvertical or Wise-
pattern mastopexy.
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Breast Reduction
For the uncommon MWL patient who retains excess breast volume, standard breast reduction techniques
can be employed to provide improved breast shape and position on the chest wall. Although all breast
reduction techniques may be considered, the superior safety profile of the inferior pedicle should be
taken into account, given the lengthy sternal notch-to-nipple distance typical of weight loss patients. A
Wise skin pattern is most commonly chosen to reduce the large skin excess. Dermal suspension
techniques and pedicle-shaping sutures as used in mastopexy procedures may improve long-term
outcomes and patient satisfaction. 20–22
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Mastopexy
For patients with sufficient volume, standard mastopexy techniques may be employed with the addition
of dermal flaps or pedicle-shaping sutures to provide support and maintain breast shape (see Figure
66.4). The entire Wise pattern is deepithelialized. The lateral most extension of the breast into the axilla
may be removed to facilitate a smooth lateral breast border. Skin flaps are then raised approximately
1.5 cm in thickness. The medial and lateral aspects of the deepithelialized breast parenchyma are elevated
at the level of the chest wall, maintaining blood supply to the NAC via the preserved 8 to 10 cm inferior
and central mound. The inferior pedicle is plicated, leaving 5 to 5.5 cm between the base of the areola and
the IMF. Medial, lateral, and superior sections are then tacked to the pectoralis fascia or rib periosteum
20,21 (Figure 66.8).
FIGURE 66.8 Mastopexy with pedicle-shaping sutures. A. An 8 to 10 cm inferior and central pedicle is marked around the
breast meridian (dotted area). B. The dermal flap sections are deepithelialized and tacked to the chest wall to support the
pedicle shape. C. The shaped pedicle resembles the appearance of an implant; however, it descends more than an implant
with healing, resulting in less sustained upper pole fullness.
If the degree of excess skin and ptosis is less severe, a vertical/extended vertical mastopexy with
preservation and advancement of the inferior pole tissues can be considered. 23
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Autologous Autoaugmentation
An appealing option for the MWL patient interested in improved breast contour and volume is
mastopexy with autologous autoaugmentation using an intercostal artery perforator (ICAP) flap/spiral
flap. 20,24–26 This procedure can simultaneously address multiple deformities at once, taking advantage of
excess axillary and posterior trunk tissue to provide increased superior pole volume, improved lateral
breast definition, and correction of axillary/back irregularities. However, the technical challenges of this
technique in achieving adequate mobilization of the flap without injuring the ICAPs have made
augmentation using an implant a preferred approach.
For the ICAP flap, patients are marked for a standard inferior-pedicle Wise-pattern mastopexy with
extension into the axillary and back regions. Sentinel to this procedure is preservation of the ICAP(s). A
Doppler probe is used to confirm perforator location anterior to the anterior axillary line. The flaps are
raised from posterior to anterior in the subfascial plane. To obtain adequate rotation of the flap for inset,
perforating vessels from the thoracodorsal system must be sacrificed. The skin flaps and inferior pedicle
are defined as per routine, and then the mobilized ICAP flap is rotated around the inferior pedicle and
secured to the chest wall medially, superiorly, and laterally. Layered closure is performed over a drain.
Inadequate mobilization leads to a boxy breast with lateral fullness. Failure to preserve the intercostal
arteries leads to fat necrosis. 20,24–26
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Augmentation Mastopexy
For patients who desire more superior fullness, mastopexy with implants is recommended in one or two
stages. Owing to the thin, overstretched skin typical of MWL patients, patients are advised to choose a
conservative implant size, and two stages may be considered for more predictable results.
In one-stage augmentation mastopexy, the implant pocket is approached through a vertical or IMF
incision by preserving the superior and medial blood supplies to the breast. A vertical approach is
advantageous for easier exposure compared with an IMF incision because the lateral fold is often
anatomically low and for preservation of the inferior breast tissue and fold centrally. The implant is
placed subpectorally in a dual plane or in a subglandular position, and a circumvertical or Wise-pattern
mastopexy is then tailor-tacked around the implant (Figure 66.9).
FIGURE 66.9 Augmentation mastopexy with an implant. A. This patient had breast ptosis and loss of volume. B. She
underwent a single-stage augmentation mastopexy with a silicone implant and had a lower body lift at a later date.
In two-stage augmentation mastopexy, the mastopexy is performed first followed by the augmentation
procedure 3 to 6 months later. If the inferior blood supply to the nipple is preserved for the mastopexy,
care is taken to make a lateral IMF incision for implant placement. If instead the superior/medial blood
supply was preserved for the breast lift, the vertical incision may be used to place the implant.
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Axilla and Upper/Middle Back Contouring
Excess adiposity and skin laxity of the upper and middle back occurs following MWL or simply as a
result of the natural aging process. For patients concerned with the appearance of this region, axillary and
back roll excision can be achieved via posterior midback/bra-line lift. This procedure can be performed in
conjunction with breast contouring or may be added as a second stage. There are theoretical concerns
about opposing vectors if performed at the same time as a belt lipectomy/lower body lift; however, both
procedures rely primarily on lifting of the inferior tissues superiorly, so they may be performed together
safely and effectively in experienced hands.
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Preoperative Evaluation, Planning, and Marking
Evaluation of the degree of excess skin and adipose tissue forms the basis for operative planning. Patients
must be willing to accept potentially significant scarring in exchange for improved contour.
According to the Pittsburgh Weight Loss Deformity Scale, 27 the posterior trunk can be evaluated
according to a four-point scale:
Grade 0: Normal contour of the back
Grade 1: Excess adiposity or a single fat roll
Grade 2: Multiple skin and fat rolls
Grade 3: Ptosis of the fat rolls
It is useful for female patients to wear a bra in the initial phase of marking, as this can help determine scar
placement—ideally hidden by the posterior bra strap. Once bra strap borders have been marked, the bra
is removed. For male patients or patients who do not present with an appropriate undergarment, the
ideal placement of the final scar should be set at the level of the planned IMF. The superior incision is
designed immediately above the planned final scar; the lower incision can be expected to elevate
significantly during closure and is based on a pinch test. The incisions extend from the lateral IMF, along
the lateral chest wall, to the posterior chest (see Figure 66.4). The bimanual examination defines how far
this excision extends. Severe deformities will require a scar that crosses the midline to avoid a dog-ear.
However, for less severe deformity, the central skin of the back is preserved and bilateral wedge excisions
are performed. Vertical realignment marks may assist with final closure.
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Surgical Technique
The procedure is performed under general anesthesia. The patient is placed in the prone position on gel
rolls, with arms flexed at the elbow and extended in the superman position. Care is taken to avoid
pressure in the axilla. If excess adiposity extends inferior to the planned excision, liposuction is first
performed in this area via separate stab incisions. The superior incision is made and carried down
through Scarpa fascia using electrocautery (Figure 66.10). The tissue is undermined at the level below
Scarpa fascia, leaving fat on the fascia to help prevent seroma. The proposed inferior mark is then
rechecked with a pinch test, and the excision is completed. Closure is then performed in three layers over
a drain. The wound is dressed with surgical glue and steri strips, covered with tegaderm dressings. The
patient is then placed supine for completion of the excision or concurrent surgery of the breast and/or
arms.
FIGURE 66.10 Bra-line lift. The excess tissue of the back is removed at a level just below Scarpa fascia.
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A compression bra, vest, or ace wrap should be placed at the conclusion of surgery. Patients should avoid
heavy lifting for 6 weeks postoperatively. Drains are removed at the first postoperative visit. The most
common complication reported with this procedure is widening of the scar. Wound healing
complications, seroma, hematoma, and infection can also occur. 28–32 A postoperative result is depicted in
Figure 66.11.
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FIGURE 66.11 Bra-line lift result. This 44-year-old Asian woman had a bra-line lift combined with a lower body lift and
augmentation mastopexy. Liposuction was performed of the midback region and flanks below the bra-line lift. The scar remains
covered with a bra.
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Combined Surgery
The decision on whether to combine one or more surgical procedures into one operative setting depends
upon the age, health, and desire of the patient as well as planned operative time and experience of the
surgeon. Upper body contouring procedures are not associated with excessive amounts of blood loss.
Therefore, an upper body lift including brachioplasty, excision of axillary and back rolls/bra-line lift, and
breast contouring can be combined into one operative procedure in many patients. 5 Upper body
contouring can also be combined with lower body contouring procedures; however, a total body lift is
typically avoided secondary to excessive operative time, blood loss, and morbidity. There are patient
advantages in combined surgeries for time off work and overall costs. 5 However, each patient must be
evaluated individually to determine the risk/benefit ratio and to determine the optimal procedure for
them.
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Questions
1. A 43-year-old woman lost 150 lb through diet and exercise. She had excess skin in her upper arms
and underwent a brachioplasty procedure. The patient has persistent numbness in the volar ulnar
surface of the forearm. Which nerve was most likely injured during the procedure:
a. Intercostobrachial
b. Lateral antebrachial cutaneous
c. MABC
d. Medial brachial cutaneous
2. A 30-year-old woman who has lost 110 lb after gastric bypass presents for evaluation. She is
interested in addressing the excess skin of her upper arms, as this causes her significant distress and
difficulty with clothing fit. When counseling the patient about the risks of surgery, which of the
following is most likely to lead to dissatisfaction with results and reoperation?
a. Wound dehiscence
b. Hypertrophic scar
c. Seroma
d. Numbness
e. Contour irregularities
3. A 54-year-old woman presents to the office 24 months after gastric bypass surgery. She has lost a
total of 170 lb and maintained a stable weight for the past 6 months. Her breasts are characterized by
grade 3 nipple ptosis and volume fitting into a C cup bra. She would like to have a more youthful
appearance. Which of the following is least likely to offer a satisfactory result?
a. Mastopexy
b. Mastopexy with autoaugmentation using an ICAP flap
c. Breast augmentation alone
d. Augmentation mastopexy
4. Which of the following best describes the characteristics most commonly associated with breast
appearance following MWL?
a. Deflated superior pole, lateralized NAC position, lowered IMF position
b. Deflated superior pole, medialized NAC position, lowered IMF position
c. Deflated superior pole, medialized NAC, raised IMF position
d. Deflated inferior pole, medialized NAC position, lowered IMF position
e. Deflated inferior pole, lateralized NAC position, raised IMF position
5. A 60-year-old woman presents for consideration of upper body contouring following previous
mastopexy. She is primarily concerned about the appearance of her back and posterior trunk.
Physical examination is significant for multiple loose, hanging rolls of skin and soft tissue. Which of
the following grades best described this deformity, according to the Pittsburgh Weight Loss
Deformity Scale?
a. Grade 0
b. Grade 1
c. Grade 2
d. Grade 3
1. Answer: c. The MABC nerve is the most commonly cited sensory nerve injury following
brachioplasty. The nerve pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle and travels with the basilic vein in the superficial plane of the distal half to third of the
upper arm. To prevent this complication, at least 1 cm of fat should be left on the deep brachial fascia
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of the upper arm.
2. Answer: b. The most common reason for patient dissatisfaction or reoperation after brachioplasty
is unsightly scarring. Patients undergoing this procedure should understand that they are trading
improved contour for a significant scar. Because of the tension forces of the upper extremity,
thickening or widening of this scar is not uncommon and may require laser treatment, kenalog
injections, or revisional surgery to improve scar appearance.
3. Answer: c. For patients with MWL, the breast deformity nearly uniformly involves breast ptosis.
An implant alone would not be expected to lift the nipple position enough for a satisfactory result. A
mastopexy is typically involved, with or without augmentation procedures, or as part of a breast
reduction to achieve a good result.
4. Answer: b. The loss of volume and attenuation of soft tissue, skin, and ligamentous support
associated with MWL results in deflated, ptotic breasts that little resemble the ideal, youthful breast.
Characteristic findings include superior pole deficiency, lack of lateral breast definition, medial NAC
position, and inferior IMF when compared with normal breast anatomy.
5. Answer: d. According to the Pittsburgh Weight Loss Deformity Scale, the posterior trunk can be
evaluated according to a four-point scale. A score of “0” indicates a normal contour of the back.
Patients with excess adiposity or a single fat roll are classified as grade 1; multiple skin and fat rolls
are classified as grade 2. Ptosis of these rolls represents the most severe stage, grade 3. In this patient
with multiple loose, hanging rolls of skin and soft tissue, her physical examination findings would
qualify as a grade 3 deformity.
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References
American Society for Metabolic and Bariatric Surgery. 2016 Statistics. Available at
numbers. Accessed March 22, 2018.
American Society for Aesthetic Plastic Surgeons. 2016 Statistics. Available at
Stats2016.pdf. Accessed March 22, 2018.
Gusenoff, JA, Rubin, JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28:452-455.
Bossert, RP, Rubin, JP. Evaluation of the weight loss patient presenting for plastic surgery consultation. Plast Reconstr Surg. 2012;130:1361-
1369.Based on years of experience with the massive weight loss population, this paper provides an excellent overview of the complex factors that must be
considered in the perioperative period. Medical comorbidities and risk factors associated with obesity are reviewed, as are the psychosocial factors that
help determine the patient’s candidacy for surgery and chances for a successful outcome.
Colwell, AS, Borud, LJ. Optimization of patient safety in postbariatric body contouring: a current review. Aesthet Surg J. 2008;28:437-442.An
extensive literature review was performed to examine and present consensus guidelines for preoperative, intraoperative, and postoperative management
of the postbariatric body-contouring patient. This study includes an important discussion of the role of venous thromboembolism prophylaxis among
this patient population and provides risk stratification guidelines invaluable for patient counseling and surgical planning.
Iturraspe, M, Fernandez, JC. Brachial dermolipectomy [in Spanish]. Prensa Med Argent. 1954;41:2432-2436.
Shermak, MA. Aesthetic refinements in body contouring in the massive weight loss patient: part 2. Arms. Plast Reconstr Surg. 2014;134:726e-
735e.Review article examining evolving trends in brachioplasty classification systems and operative techniques. Succinct overview of relevant anatomy,
current practice, and reported outcomes.
Teimourian, B, Malekzadeh, S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545-551.
Appelt, EA, Janis, JE, Rohrich, RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237-246.
El Khatib, HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119:1337-1342.
Ferraro, GA, De Francesco, F, Razzano, S, et al. Modified fish-incision technique in brachioplasty: a surgical approach to correct excess skin
and fat of the upper arm (restoring the armpit contour). Aesthetic Plast Surg. 2015;39:203-208.
de Runz, A, Colson, T, Minetti, C, et al. Liposuction-assisted medial brachioplasty after massive weight loss: an efficient procedure with a
high functional benefit. Plast Reconstr Surg. 2015;135:74e-84e.
Hill, S, Small, KH, Pezeshk, RA, Rohrich, RJ. Liposuction-assisted short-scar brachioplasty: technical highlights. Plast Reconstr Surg.
2016;138:447e-450e.Technique article detailing markings and surgical approach for minibrachioplasty/limited medial incision brachioplasty.
Hurwitz, DJ, Holland, SW. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest.
Plast Reconstr Surg. 2006;117:403-411.Technique article introducing the indications for L-brachioplasty, as well as design, surgical approach, and
expected patient outcomes.
Gentileschi, S, Servillo, M, Ferrandina, G, Salgarello, M. Lymphatic and sensory function of the upper limb after brachioplasty in post-
bariatric massive weight loss patients. Aesthet Surg J. 2017;37:1022-1031.
Nyugen, L, Gupta, V, Afshari, A, et al. Incidence and risk factors of major complications in brachioplasty: anaylsis of 2294 patients. Aesthet
Surg J. 2016;36:792-803.
Meaume, S, Le Pillouer-Prost, A, Richert, B, et al. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol.
2014;24:435-443.
Blumgart, EI, Uren, RF, Nielsen, PM, et al. Lymphatic drainage and tumour prevalence in the breast: a statistical analysis of symmetry,
gender, and node field independence. J Anat. 2011;218:652-659.
Manca, G, Volterrani, D, Mazzarri, S, et al. Sentinel lymph node mapping in breast cancer: a critical reappraisal of the internal mammary
chain issue. Q J Nucl Med Mol Imaging. 2014;58:114-126.
Colwell, AS, Driscoll, D, Breuing, KH. Mastopexy techniques after massive weight loss: an algorithmic approach and review of the literature.
Ann Plast Surg. 2009;63:28-33.Review article highlighting anatomical changes of the breasts associated with massive weight loss. The authors conduct
a literature review examining various techniques for correction of MWL-associated deformities of the breast and offer an algorithmic approach for the
management of such.
Rubin, JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J. 2006;26:214-222.The
author presents a technique that achieves improved breast contour and volume using the patient’s own tissues. This technique has the added advantage
of correcting the lateral axillary roll frequently seen in patients following massive weight loss.
Colwell, AS, Breuing, KH. Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings. Ann Plast Surg.
2008;61:138-142.
Losken, A, Holtz, DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotation-advancement
technique. Plast Reconstr Surg. 2007;120:1060-1068.
Kwei, S, Borud, SJ, Lee, BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap.
Ann Plast Surg. 2006;57:361-365.The authors of this technique paper describe the ICAP flap for autologous autoaugmentation. The article includes
detailed information regarding indications for the procedure, surgical planning and execution, and expected outcomes.
Hamdi, M, Van Landuyt, K, Blondeel, P, et al. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive
weight loss patients. J Plast Reconstr Aesthet Surg. 2009;62:65-70.
Hamdi, M, Van Landuyt, K, de Frene, B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg.
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2006;59:644-652.
Song, AY, Jean, RD, Hurwitz, DJ, et al. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast
Reconstr Surg. 2005;116:1535-1544.The authors devise a 10-region, 4-point grading scale for the purpose of providing a validated measure of contour
deformities following massive weight loss. This scale can assist with communication between providers, preoperative planning, and patient counseling.
Hunstad, JP, Repta, R. Bra-line back lift. Plast Reconstr Surg. 2008;122:1225-1228.
Hunstad, JP, Khan, PD. The bra-line back lift: a simple approach to correcting severe back rolls. Clin Plast Surg. 2014;41:715-726.The authors
review relevant anatomy, preoperative markings, and intraoperative technique for the bra-line back lift. The article is accompanied by clear photographs
and a concise overview of postoperative care requirements, possible complications, and outcomes.
Shermak, MA. Management of back rolls. Aesthet Surg J. 2008;28:348-356.
Soliman, S, Rotemberg, SC, Pace, D, et al. Upper body lift. Clin Plast Surg. 2008;35:107-114.
Strauch, B, Rohde, C, Patel, MK, Patel, S. Back contouring in weight loss patients. Plast Reconstr Surg. 2007;120:1692-1696.
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PA R T V I I I
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Hand
67. Functional Anatomy and Principles of Upper Extremity Surgery
68. Hand Infections
69. Soft Tissue Reconstruction of the Upper Extremity and Management of Fingertip and Nail Bed Injuries
70. Management of Compression Neuropathies of the Upper Extremity
71. Principles and Applications of Nerve Transfers
72. Management of Brachial Plexus Injuries
73. Tetraplegia
74. Management of Hand Fractures
75. Management of Wrist Fractures
76. Flexor Tendon Repair and Reconstruction
77. Extensor Tendon Repair and Reconstruction
78. Tenosynovitis Disorders of the Upper Extremity
79. Principles and Applications of Tendon Transfers
80. Ligament Injuries of the Hand
81. Ligament Injuries of the Wrist
82. Management of Mutilating Upper Extremity Injuries
83. Replantation Strategies of the Hand and Upper Extremity
84. Thumb Reconstruction
85. Dupuytren Disease
86. Hand Tumors
87. Treatment of Vascular Disorders of the Hand
88. Comprehensive Management of the Burned Hand
89. Compartment Syndrome of the Upper Extremity
90. Common Congenital Hand Anomalies
91. Upper Limb Amputations and Prosthetics
92. Rheumatoid Arthritis and Inflammatory Arthropathies
93. Osteoarthritis
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C H A P T E R 6 7
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Functional Anatomy and Principles of Upper
Extremity Surgery
Robert A. Weber and Wendy L. Czerwinski
Key Points
The anatomy of the upper extremity follows a form that maximizes its functional output.
Understanding the relationship between surface landmarks and underlying anatomy facilitates safe
and efficient hand surgery.
A standardized template that identifies functional deficits can facilitate the evaluation of a hand
surgery patient to arrive at an accurate diagnosis.
The restoration of motor and sensory function in the hand is the focus of an upper extremity
treatment plan.
Patient outcomes can be improved by following the principles of Enhanced Recovery After Surgery.
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Functional Anatomy
Form follows function is a particularly useful aphorism when considering the upper extremity. The
appearance of the arm is determined by its anatomy, which in turn is a result of the functional demands
placed upon it. As such, a way to understand the anatomy of the upper extremity is to think in the
following terms: bones, joints, and ligaments function as the foundation, muscles and tendons function
as motors, arteries and veins function as fuel, nerves function to control, and the skin and subcutaneous
tissues function as the surface interface.
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Bony Foundation
The primary function of the upper extremity skeleton is to provide a stable foundation for purposeful
movement. The bones anchor the origin and insertion of musculotendinous units. As such, bone injuries
often have concomitant musculotendinous injuries. The bones also resist the compressive and bending
forces that these muscles produce, so immobilization must relieve the torque and not create tension in the
bone. The joints channel the compressive forces into motion; the configuration of the joints and the
constraint of the ligaments determine the degrees of freedom. The majority of functional motion in the
arm is flexion and extension in the anterior/posterior plane. The metacarpophalangeal (MP),
carpometacarpal (CMC), and wrist joints also allow small amounts of rotation in other axes in order to
conform to objects and dissipate forces.
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Forearm
The radius and ulna have flat surfaces for multiple muscle origins and insertions. The ulna is constrained
to flexion and extension at the elbow, whereas the radius can perform these actions and is also able to
rotate longitudinally at the elbow and circumduct around the ulna distally, resulting in proximal
translation of the distal radius relative to the distal ulna during pronation. This relative shortening of the
radius can cause the distal ulna to impact the lunate or triquetrum (Figure 67.1). The primary stability of
the distal radioulnar joint (DRUJ) is provided by the triangular fibrocartilage complex (TFCC) (Figure
67.2); the bony configuration of the sigmoid notch of the radius provides 30% of the DRUJ stability.
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FIGURE 67.1 AP radiograph of the hand. a. Location for ulnocarpal impaction due to relative shortening of the radius during
pronation. b. Hook of the hamate. c. Head of the MP demonstrating the recesses where the collateral ligaments insert as well
as the ball-and-socket like configuration of the joint. d. Bicondylar configuration of the PIP joint adds conformational stability to
flexion and extension. e. Thumb CMC joint is a saddle joint, which allows flexion and extension in the AP and radioulnar planes
(unlike the other CMC joints) and prohibits axial rotation (unlike the MP joints). Note the natural ulnar deviation at the MP joints.
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FIGURE 67.2 The TFCC is a complex arrangement of seven soft tissue structures of the ulnar wrist. This includes the TFC
proper (a meniscus homologue), the dorsal and volar radioulnar ligaments, the three volar ulnocarpal (UC) ligaments
(ulnolunate [UL], ulnocapitate, ulnotriquetral [UT]), and the floor of the extensor carpi ulnaris tendon subsheath. The UC
ligament sits volar to the UL and UT ligaments.
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Wrist
The radius and ulna articulate distally with the carpus. Because there are no tendinous insertions in any
of the carpal bones, the osseous shapes as well as the extrinsic and intrinsic ligaments are vital for
functional stability. For the purpose of motion, carpal bone arrangement is usually considered as two
arched rows with the lunate as the keystone and the scaphoid extending to both rows. Gilula’s arcs
represent the curvatures of a ball-within-a-cup configuration of the proximal and distal carpal rows (see
Figure 67.1). 1
The hamate bone has a palpable volar hook that is visible on carpal tunnel view radiographs and
represents an attachment of the flexor retinaculum, hypothenar muscles, and pisohamate fascia of the
Guyon canal (see Figure 67.1).
The radiocarpal (RC) and the ulnocarpal (UC) joints are restrained by the joint capsule, the volar
radioscaphocapitate ligament (the strongest ligament), the long radiolunate ligament, short radiolunate
ligament, and the ligament of Testut. 2 The primary dorsal ligaments consist of the dorsal radiocarpal
ligament and dorsal intercarpal ligament. A dorsal carpal surgical exposure with a dorsal ligament
sparing capsulotomy attempts to preserve the integrity of these structures, thereby improving
postoperative stability and mobility. 3 Intrinsic ligaments provide stability between carpal bones within
the proximal and distal rows but not between rows and lead to coordinated flexion and extension of these
rows. Disruption of intrinsic ligaments can create various instability patterns such as those seen in greater
and lesser arc perilunate injuries. 4
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Hand
The metacarpal (MC) bones have a collateral recess radially and ulnarly at their heads for the origin of the
proper collateral ligaments (CL) of the metacarpal-phalangeal (MP) joints. These recesses are
radiographically visible and serve as excellent insertion points for ideal angulation in placing
longitudinal K-wires for fracture fixation (see Figure 67.1). The dorsal convexity of the MC bone results in
tension on the dorsal surface with loading, leading to dorsal apex fracture patterns. The MP joints are
condyloid in nature, allowing for motion in three planes: flexion/extension, abduction/adduction, and
rotation. The volar plate is contiguous with the deep transverse MC ligament, which connects the
metacarpal heads and helps maintain the MCs in a slight dorsal arch in the transverse plane. Because the
MC head is wider on its volar surface, flexion increases joint stability by tightening the CL and elongating
the VP. Thus, the MP joint should be immobilized in flexion to reduce the occurrence of joint
contractures. In extension, the MPs are not linear. Instead, there is a 10- to 14-degree natural ulnar
deviation, predisposing the finger to ulnar subluxation of the extensor hood and ulnar drift (see Figure
67.1). The carpometacarpal (CMC) joints have limited mobility at the index finger and become
progressively more mobile toward the ulnar aspect of the hand, allowing for approximately 30 degrees of
flexion/extension at the fourth and fifth with some supination.
The phalangeal heads are bicondylar and form interphalangeal uniaxial hinge joints (see Figure 67.1). The
interphalangeal (IP) joints have one axis of rotation in flexion and extension due to their bony
configuration as well as a complex arrangement of ligaments, volar plate (VP), joint capsule, and a stout
extensor mechanism that resists joint dislocation. Small volar checkrein ligaments arising from the
proximal phalanx volar ridges to the VP are thought to contribute to flexion contractures, which can arise
at the PIP joints. In contrast to the MP joints, the PIP joints should be splinted in full extension.
The thumb bones are pronated about 90 degrees and volarly abducted about 45 degrees from the plane of
the hand. This configuration is what allows the functions of prehension: tip pinch, chuck pinch, key
pinch, and grasp. The thumb’s MP joint is a shallow ball-and-socket, which permits the thumb phalanges
to pronate even more than the metacarpal. Soft tissues are more dominant in creating joint support with
the addition of the adductor aponeurosis overlying the ulnar CL. The basilar or carpometacarpal (CMC)
joint is a saddle or double ginglymus joint allowing for circumductive motion, and the primary stabilizer
is the volar beak/oblique ligament (see Figure 67.1). Laxity of this ligament is considered the origin of first
CMC articular changes.
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Makers of Movement
The musculotendinous systems of the arm create tension, which is transmitted from the origin to
insertion. Working primarily as class 3 levers, longitudinal contraction of the muscle results in rotation
around the joint axis. The primary motion is flexion and extension, and the flexors are able to generate
more force than the extensors. The primary function of the extensors is to place the hand and fingers in a
position to be used optimally. The work of the arm is done by the flexors. Repair or reconstruction of a
musculotendinous unit requires that the tension forces be transmitted across the injured site in such a
way to minimize adherence to adjacent structures.
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Extensors
The musculotendinous system can be differentiated into extrinsic muscles originating in the forearm and
intrinsic muscles of the hand including the thenar group. The extrinsic extensors, which are in three
groups of three, originate from the dorsal-radial surface of the forearm and serve to extend the wrist,
thumb, and remaining digits primarily at the MP level with some contribution to IP extension (Figure
67.3). They are all innervated by the radial nerve. At the wrist, they pass deep to an extensor retinaculum
organized into six compartments with extensor indicis proprius (EIP) and extensor digiti minimi
providing independent extension of the index and small digits and usually lying ulnar to their
corresponding extensor digitorum communis (EDC) counterparts. The EIP is a useful donor motor
tendon for functional transfers and can be identified by its muscle belly distal most in the dorsal forearm.
The juncturae tendinae, which are interconnections between the extensors over the dorsal hand, can
confuse diagnosis of tendon disruptions by the ablility to extend fingers with ruptured tendons to neutral
posture through the juncturae tendinae.
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FIGURE 67.3 The extrinsic wrist extensors (extensor carpi radialis longus [ECRL], extensor carpi radialis brevis [ECRB],
extensor carpi ulnaris [ECU]), thumb extensors (extensor pollicis longus [EPL], abductor pollicis longus [APL], extensor pollicis
brevis [EPB]), and finger extensors (extensor digitorum communis [EDC], extensor indicis proprious [EIP], extensor digiti minimi
[EDM]) are organized into 6 compartments with EIP and EDM providing independent extension of the index and small digits and
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usually lying ulnar to their corresponding EDC slips. The extrinsic tendons continue over the digit stabilized by the extensor
hood. The tendinous system continues and becomes a W over the PIP joint. The tendon inserts as the central slip over the
middle phalanx with contributions to the lateral bands which extend distally to the terminal triangular ligament over the DIP joint
and inserting just proximal to the germinal matrix. The dorsal and volar interossei and lumbricals are intrinsic muscles
contributing to the lateral bands running volar to the MP joint axis.
The extrinsic tendons continue onto the digit stabilized at the MP joint by the extensor hood/sagittal band
(see Figure 67.3). Disruption at this level contributes to improper tendon tracking, and the radial-sided
laxity seen in inflammatory joint conditions contributes to ulnar drift. There are no extensor insertions on
the proximal phalanx. Instead, the sagittal bands transmit tension to the volar plate to pull the proximal
phalanx into extension. At the PIP joint, the intrinsic muscles of the hand join the extensor mechanism
(see Figure 67.3). They contribute to the lateral bands, which pass volar to the MP joint axis and thus aid
in flexion at that joint. The intrinsic insertions then move dorsal to the axis of the PIP joint and function as
the primary IP extensors. The PIP and DIP joints will not extend if the intrinsic muscles do not contract.
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Flexors
There are 11 extrinsic flexors, 9 of which pass through the carpal canal (Figure 67.4). The majority of
flexors are innervated by the median nerve; the ulnar nerve innervates the flexor carpi ulnaris (FCU) and
the flexor digitorum profundus (FDP) to the ring and small digits; however, innervation variability exists
in the forearm. The flexor tendon sheath extends from the proximal edge of the A1 pulley to the DIP joint,
provides tendon nutrition and facilitates glide. Annular pulleys (A1-A5) are numbered from proximal to
distal with three compressible cruciate pulleys intervening from A2 to A5. These prevent bowstringing in
order to allow for improved excursion/moment arcs at the corresponding joint levels.
FIGURE 67.4 The FDS runs superficial to FDP and FPL in the carpal tunnel but then has a longitudinal splint near its insertion
across the PIP joint (Camper’s chiasm), which permits FDP to run superficially to reach the distal.
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Intrinsic Tendons
In addition to their contributions to MP flexion and IP extension, the interossei are also responsible for
digit adduction and abduction. The first dorsal interosseous muscle is the last innervated muscle by the
ulnar nerve; thus, wasting and weakness assessed are often first noted here by Froment’s test. The
adductor pollicis (AdP) is responsible for thumb adduction. The thenar group is innervated by the
median nerve, whereas the deep head of FPB and the transverse head of the AdP are innervated by the
ulnar nerve. Although this group contributes to precise thumb motion, patients with long-standing carpal
tunnel syndrome and thenar wasting are often not aware of any functional deficit.
The intimate relationship between the intrinsic muscles and the metacarpals is critical to keep in mind.
Metacarpal fractures will always have concomitant interosseous muscle damage. As a result, a fracture
may heal completely with anatomic configuration, yet the hand may have significant weakness with grip
or finger extension due to derangement of the muscles. A similar apposition is present between the
phalanges and the flexor/extensor tendons of the finger, wherein a finger fracture can have significant
concomitant tendon involvement.
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Fuel and Control
The arteries provide metabolic support for the hand, but the majority of blood flow is used for
thermoregulation. Within the arm and hand, the arteries and nerves tend to run parallel within a
common sheath, protected from compression by the bones and tendons. The neurovascular structures can
tolerate some tension and are able to glide longitudinally within the extremity to accommodate the
various positions of the bones and joints. Adhesions that restrict gliding can produce pain and interfere
with functionality.
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Arteries
The brachial artery at the elbow divides into the radial and ulnar arteries in the antecubital fossa. The
radial artery runs in a course toward the radial wrist radial to the FCR. There is a larger dorsal branch
that passes through the snuffbox to the deep arch in the palm. The small volar branch contributes to the
superficial arch. The ulnar artery runs between the FDS and FDP muscle groups and is palpable radial to
the FCU. It continues radial to the ulnar nerve through the Guyon canal; its larger volar branch completes
the superficial arch, whereas the smaller dorsal branch completes the deep arch. Vascularity to the carpus
arises from the posterior and anterior interosseous arteries as well as from the ulnar and radial arteries at
the level of the wrist. The common digital arteries arise from the superficial arch, whereas the princeps
pollicis artery to the thumb arises from the radial artery portion of the deep arch. Vascular architecture
varies from individual to individual, but within every hand, there are numerous redundant arterial
interconnections, so disruption of one artery is unlikely to result in terminal ischemia. Nevertheless,
arterial supply to the hand or a digit should be examined before deciding to ligate or not to repair an
artery.
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Nerves
The peripheral nerves originate from the cervical roots and form the brachial plexus. The median, ulnar,
and radial nerve branches that terminate in the hand have fairly consistent anatomic relationships.
Cranial to caudal nerve roots correspond to proximal to distal motor control, that is, the shoulder girdle is
controlled by C5 nerve roots, and the intrinsic muscles of the hand are innervated from C8/T1 roots.
Sensory innervation also follows a cranial to caudal pattern; C5 provides sensation to the radial border of
the forearm, T1 provides ulnar forearm sensation.
The internal topography of peripheral nerves has functional implications. For example, some muscles
such as the FCR have multiple innervating fascicles, thereby allowing one of the fascicles to be used as
motor nerve transfer. Another example of the functional relevance of internal fascicular anatomy is seen
in the median and ulnar nerves at the wrist. The motor branches of those nerves are in a predictable
location (the median motor is volar radial, and the ulnar motor is dorsal radial), thereby allowing more
accurate nerve repairs or nerve transfers.
All the extensors in the arm are innervated by the radial nerve. The elbow flexors are innervated by the
musculocutaneous nerve, whereas the wrist and finger flexors are primarily innervated by the median
nerve. The ulnar nerve innervates the FCU, the ulnar two FDPs with their associated lumbricals, and all
the intrinsics except the thenar muscles. Like the arteries, the location of a peripheral nerve can vary from
individual to individual; nevertheless, the ulnar nerve is commonly located adherent to the ulnar artery.
The median nerve lies between the superficialis and profundus muscle bellies in the forearm, adherent to
the deep surface of the superficialis. This is important to remember when attempting to locate the nerve
during trauma exploration. Knowing the functional anatomy of the nerves also allows the surgeon to
block the nerves with a local anesthetic for diagnostic and therapeutic purposes.
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Surface Anatomy
Understanding how the surface anatomy of the upper extremity (flexion and extension creases, palpable
muscle, and bony landmarks) relates to the structures hidden beneath the skin is critical for the
management of the hand. The ability to relate what can be seen and palpated to the underlying elements
allows effective treatment of those deeper structures with a minimum of damage to the surrounding
tissues. Fortunately for the hand surgeon, there are many reliable guides on the surface of the upper
extremity.
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Forearm
With the elbow flexed at 90 degrees and the wrist in neural pronation, the muscle visible and palpable in
the anterolateral portion of the proximal forearm is the brachioradialis (Figure 67.5). The biceps tendon is
palpable ulnar to the brachioradialis in the antecubital fossa. The median nerve, anterior interosseous
nerve, and the brachial artery are ulnar to the biceps insertion. The extensor wad is dorsal to the
brachioradialis.
FIGURE 67.5 Right forearm demonstrating the brachioradialis, extensor wad, palmaris longus tendon, and FCR tendon.
In the distal volar forearm, flexion of the wrist simultaneous with positioning all the finger tips together
reveals the palmaris longus tendon, a source of tendon graft. The palmaris longus (PL), used as both a
tendon graft and motor tendon transfer, is absent unilaterally in about 15% of the population and
bilaterally in 8%. The median nerve is radial to the PL tendon, with the flexor pollicis longus tendon deep
to the nerve. All the flexor digitorum superficialis and profundus tendons are ulnar to the PL tendon.
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Volar Hand
The volar skin creases provide many landmarks to the musculoskeletal and neurovascular architecture. 5
Figure 67.6 shows the relationship between the major flexion creases and the underlying anatomy. The
distal wrist crease lies at the midcarpal joint corresponding to the capitolunate articulation. The distal
pole of the scaphoid is distal to the crease. The crease also identifies the proximal edge of the transverse
carpal ligament and can be used as a landmark for median nerve blocks. The distal palmar crease overlies
the metacarpal necks and is 5 to 8 mm proximal to the metacarpal-phalangeal (MP) joints. This crease
should be visible when making volar splints that are intended to immobilize the wrist while allowing MP
motion. The misleadingly named MP crease is actually at the same level as the web space and overlies the
midportion of the proximal phalanx. The proximal interphalangeal (PIP) and distal interphalangeal (DIP)
creases are superficial to the actual joints. They can be used to locate the underlying flexor tendon
pulleys. The thenar crease is due to CMC motion and must be visible in any immobilization in which the
thumb is allowed to move. The radial digital nerve to the index finger runs deep to the thenar crease. The
thumb MP and IP creases overlie the corresponding joints.
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