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

Single-Stage Phalloplasty With Two Flaps
Because of the very large donor defect on the forearm and concerns about reduced vascularity at the
periphery of large free-flap skin paddles, the simultaneous use of two separate flaps, one for the urethra
and one for the phallus have been described. Common combinations include a small radial forearm or
ulnar forearm free flap for the urethral component and a pedicled ALT flap for phallic skin or a pedicled
superficial circumflex iliac artery perforator flap for the urethra and an ALT flap for phallic skin. Multiple
other permutations of flaps have been proposed and tried; this heterogeneity underscores the significant
challenge of phallic construction.
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Staged Phalloplasty
In an attempt to overcome the high urethral stricture and fistula rates observed after single-stage
phalloplasty, staged procedures have been proposed. One strategy is to perform a urethral lengthening (a
construction of the pars fixa urethra) or even a full metoidioplasty as a first stage, followed by the flap-
based phalloplasty as a second stage. In this approach, the pars fixa urethra is constructed in the same
way as for single-stage phalloplasty, but it is allowed to heal completely before the phalloplasty flap
procedure is performed.
Another strategy has been to prefabricate the penile urethra prior to phalloplasty. 44 Several months in
advance of the planned phalloplasty, the donor flap is partially raised; and vaginal mucosa, buccal
mucosa, or skin grafts are tubed around a catheter within the substance of the flap. This neourethra is
allowed to mature for several months before the entire donor flap is raised and transferred as the
neophallus.
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Scrotal Construction
Scrotal construction is generally begun at the time of phalloplasty using hair-bearing flaps from the labia
majora. It is important to place the neoscrotum in its normal anatomic location, anterior to the perineum
at the base of the phallus so as not to interfere with the legs while walking. Multiple specific designs for
scrotal reconstruction have been described, with the most commonly used strategy likely being a V-Y
plasty of the labia majora in combination with labial flaps rotated 90°, thereby recruiting additional skin
anteriorly.
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Prostheses for Erectile Function
Semirigid or hydraulic prostheses have been used to achieve erection in phalloplasty patients. The
insertion of the prosthesis is always delayed, generally for at least a year, after phalloplasty. Multiple
strategies to encase the prostheses in synthetic or biologic sheaths and to anchor the prosthesis to the
pubis have been proposed to overcome the high complication rate associated with penile prostheses in
phalloplasty patients. Because most centers still report a 30% or higher rate of extrusion necessitating
removal within 2 or 3 years of prosthesis placement and because reoperation rates approach 100% at
5 years, some centers decline to place penile prostheses. 45,46 As an alternative, patients can be instructed
on the use of external stiffening strategies to engage in intercourse. New prostheses, developed
specifically for phalloplasty patients, may improve success rates in the future.
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Complications and Outcomes of Phalloplasty
Because phalloplasty is a multistage, complex flap-based endeavor, patients should be informed that
complications are common. In addition to all the complications attendant with any surgery and with free-
flap surgery specifically, the rates of urinary strictures and fistulas and complications with penile
implants remain, as noted above, high despite the multiple strategies employed to lessen the frequency of
complications. 47,48
There are no high level-of-evidence studies using validated instruments to accurately define patient-
reported or health status outcomes in phalloplasty patients. However, the less rigorous data in the
existing body of literature indicate that despite the high complication rate, the overall patient satisfaction
and results of phalloplasty appear to be acceptable and that “regret” following phalloplasty is rare.
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Metoidioplasty
For patients who decline the complexity, multiple stages, and donor-site morbidity of a phalloplasty,
metoidioplasty may be a reasonable option. Testosterone therapy will result in clitoromegaly, allowing
conversion of the clitoris into a small phallus. The basic elements of the procedure include a release of the
ventral chordee of the clitoris, a release of the clitoral suspensory ligament, and lengthening of the female
urethra to exit the tip of the enlarged clitoris. The same techniques for urethral lengthening for
phalloplasties are employed: vaginal mucosal turn-over flaps, labia minora flaps, and buccal grafts,
usually in combination. Because the most critical part of this procedure is the urethral lengthening, and
because the complications of urethral strictures and fistulas are common, it is again our opinion that a
reconstructive urologist should be involved unless the Plastic Surgeon has received additional specialized
training.
The goal of metoidioplasty is to fashion a phallus to affirm male gender identity and to allow standing
micturition, although not all patients achieve this latter goal. Metoidioplasty typically results in a phallus
4 to 8 cm in length so penetrative intercourse is not generally possible (Figure 100.8).
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FIGURE 100.8 Metoidioplasty. A small phallus resulted from metoidioplasty in this patient.
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Summary
Gender-affirming surgery is a broad and growing part of Plastic Surgery. For properly selected gender
dysphoric individuals, appropriate surgical intervention can have significant, positive health and quality
of life benefits. Because the diagnosis of gender dysphoria and the selection of candidates for gender-
affirming surgical intervention are outside of the scope of expertise of Plastic Surgeons, it is essential that
care is delivered in a multidisciplinary environment and especially in collaboration with the mental
health team. The WPATH SOC should be the guiding principles for working with this patient population
and for gauging a patient’s readiness for surgery. As reviewed above, a very broad range of surgical
procedures can be considered for both transfeminine and transmasculine individuals. Facial feminization
surgery and transgender top surgery are within the scope of well-trained Plastic Surgeons. On the other
hand, genital sex reassignment procedures, both vaginoplasty and phalloplasty, involve anatomy and
may result in complications that are outside the scope of current Plastic Surgery training. Surgeons
intending to become involved in these procedures must seek additional training and should work with
gynecologic and urologic colleagues to assure appropriate patient outcomes.
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Questions
1. The neoclitoris is constructed from the dorsal aspect of the glans penis in a penile inversion
vaginoplasty operation. The nerve supplying this flap that provides erogenous sensation and
orgasmic function is the
a. Dorsal penile nerve
b. Ilioinguinal nerve
c. Pudendal nerve
d. Clitoral nerve
1. A patient presents requesting penile inversion vaginoplasty surgery. What are the prerequisites for
transfeminine bottom surgery according to WPATH criteria?
a. Two letters of readiness for surgery from mental health professionals
b. One year of living full time in congruent gender (as a woman)
c. One year of hormonal therapy including estrogen
d. All of the above
3. During the preoperative consultation for radial forearm phalloplasty, a patient asks about
postoperative urinary function. It is very important to him to be able to stand and use a urinal after
surgery. What is the incidence of postoperative urinary stricture/fistula?
a. 5%
b. 10%
c. 30%
d. 80%
4. A patient presents to the office 3 weeks following penile inversion vaginoplasty surgery
complaining of malodorous secretions from her neovagina. On examination, there is feculent
smelling discharge. What should be ruled out?
a. Vaginal candidiasis
b. Menstruation
c. Inadequate hygiene
d. Rectovaginal fistula
5. To prevent perioperative VTE, what medication should be held 3 weeks prior to vaginoplasty
surgery in transfeminine patients?
a. Spironolactone
b. Estradiol
c. Testosterone
d. Depo-provera
6. A patient desires a radial forearm phalloplasty for gender-affirming bottom surgery. Prior to the
operation the operating surgeon must perform what test?
a. Retrograde urethrogram
b. Allen’s test
c. Speculum examination
d. Angiogram of upper extremity
1. Answer: a. The dorsal penile nerve is invested between Buck fascia and the tunica of the corpus
cavernosa and together with the dorsal penile artery and veins composes the pedicle of the
neoclitoral flap.
2. Answer: d. The WPATH SOC are internationally accepted guidelines for transgender care
including prerequisites prior to genital gender-affirming surgery.
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3. Answer: c. Urinary strictures and fistula are common at the juncture of the urethral portion of the
radial forearm and the pars fixa urethra.
4. Answer: d. Rectovaginal fistula is a rare (1% incidence) but serious complication of penile
inversion vaginoplasty surgery. A temporary diverting ostomy is required to let the fistula heal in
and the patient must continue to dilate the neovagina during this time. Failure to dilate will result in
contraction of the entire neovagina.
5. Answer: b. Transfeminine patients are at elevated risk of VTE on estrogen therapy, over 14 times
that of cisgender women after 9 years of therapy. Vaginoplasty is a major 5-hour operation with
1 week of modified activity restrictions. Holding estrogen therapy is socially and emotionally
difficult for transgender women, but is necessary to prevent a postoperative pulmonary embolus.
6. Answer: b. An Allen test assesses the superficial and deep arches of the hand. Harvest of a radial
forearm flap will potentially threaten the vascular supply of the hand in patients with an incomplete
arch.
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References
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Publishing; 2013.
Flores, AR, Herman, JL, Gates, GJ, Brown, TNT. How many Adults Identify as Transgender in the United States? 2016. Available at
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World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming
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American Society of Plastic Surgeons. Comment Letter on Proposed Rule on Medicare Program: Hospital Inpatient Prospective Payment System
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August 17, 2018.
Weissler, JM, Chang, BL, Carney, MJ, et al. Gender-affirming surgery in persons with gender dysphoria. Plast Reconstr Surg. 2018;141(3):388e-
396e.The authors describe a multidisciplinary approach for the treatment of gender dysphoria treatment, and the specific role of plastic surgeons within
its collaborative, integrated care framework. They outline plastic surgery’s advancement in transgender medicine and underscore the breath of positive
health outcomes that follow gender-affirmation surgeries.
James, SE, Herman, JL, Rankin, S, et al. The Report of the 2015 US Transgender Survey. Washington, DC: National Center for Transgender
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Bockting, WO, Miner, MH, Swinburne Romine, RE, et al. Stigma, mental health, and resilience in an online sample of the US transgender
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Grant, J, Mottet, L, Tanis, J. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National
Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. Accessed August 17, 2018.
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Reisner, SL, Greytak, EA, Parsons, JT, Ybarra, ML. Gender minority social stress in adolescence: disparities in adolescent bullying and
substance use by gender identity. ML J Sex Res. 2015;52(3):243-256.
Adams, KA, Nagoshi, CT, Filip-Crawford, G, et al. Components of gender-nonconformity prejudice. Int J Transgenderism. 2016:17:185-198.
Fredriksen-Goldsen, KI, Simoni, JM, Kim, HJ, et al. The health equity promotion model: reconceptualization of lesbian, gay, bisexual, and
transgender (LGBT) health disparities. Am J Orthopsychiatry. 2014;84(6):653-663.
Deutsch, MB. Use of the informed consent model in the provision of cross-sex hormone therapy: a survey of the practices of selected clinics.
Int J Transgend. 2013(3):140-146.
Callen Lorde Community Health Center. Transgender Health Program Protocols. New York, NY: Callen Lorde Community Health Center; 2011.
Tom Waddell Health Center. Protocols for Hormonal Reassignment of Gender.
Revised May 7, 2013. Accessed August
17, 2018.
Cavanaugh, T, Hopwood, R, Gonzalez, A, Thompson, J. The Medical Care of Transgender Persons. Boston, MA: Fenway Health; 2015.
Accessed
August 17, 2018.
Cavanaugh, T, Hopwood, R, Lambert, C. Informed consent in the medical care of transgender and gender-nonconforming patients. AMA J
Ethics. 2016;18(11):1147-1155.
Coleman, E, Bockting, W, Botzer, M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people,
version 7. Int J Transgenderism. 2012;13(4):165-232.
Vance, SR Jr, Ehrensaft, D, Rosenthal, SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134:1184.
Shechner, T. Gender identity disorder: a literature review from a developmental perspective. Isr J Psychiatry Relat Sci. 2010;47:132.
Steensma, TD, McGuire, JK, Kreukels, BPC, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a
quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52:582-590.Thirty-seven percent of adolescents (<12 years old) diagnosed
with gender dysphoria at the Vrije Universiteit (VU) University Medical Center in Amsterdam, the Netherlands showed persistence of gender
dysphoria into adulthood. Ethical treatment options for trans and gender-nonconforming youth is widely debated, emphasizing the current gap in the
literature reporting childhood gender dysphoria persistence in adulthood. This study suggests predictors of gender dysphoria in adulthood, including
differences between natal sex, familial management, social transitions in childhood, and cognitive representation of gender. Better understanding of
gender dysphoria persistence can help develop improved models of care and health outcomes.
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de Vries, AL, Steensma, TD, Doreleijers, TA, Cohen-Kettenis, PT. Puberty suppression in adolescents with gender identity disorder: a
prospective follow-up study. J Sex Med. 2011;8(8):2276-2283.
Altman, K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg. 2012;41(8):885-894.
Morrison, SD, Vyas, KS, Motakef, S, et al. Facial feminization: systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770.
Song, TE, Jiang, N. Transgender phonosurgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2017;156(5):803-808.
Asscheman, H, T’Sjoen, G, Lemaire, A, et al. Venous thromboembolism as a complication of cross-sex hormone treatment of male-to-female
transsexual subjects: a review. Andrologia. 2014;46:791-795.
Hembree, WC, Cohen-Kettinis, P, Delemarre-van de Waal, HA, et al. Endocrine treatment of transsexual persons: an endocrine society
clinical practice guideline. J Clin Endocrinol Metab. 2009;9:3132-3154.
Horbach, SE, Bouman, MB, Smit, JM, et al. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical
techniques. J Sex Med. 2015;12(6):1499-1512.
Buncamper, ME, van der Sluis, WB, van der Pas, RS, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475
transgender women. Plast Reconstr Surg. 2016;138(5):999-1007.Four hundred and seventy-five transgender women who underwent penile
inversion vaginoplasty (PIV) at the VU University Medical Center between 2000-2014 were retrospectively reviewed for intraoperative and
postoperative outcomes, including complications, risk factors, reoperation and revisions, and necessitated secondary surgical procedures. This is a high-
case volume report concludes that PIV can be successfully implemented with minimal risk of intraoperative complications, and, though frequent (93%),
easily managed postoperative complications.
Goddard, JC, Vickery, RM, Qureshi, A, et al. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int.
2007;100:607-613.
Rossi Neto, R, Hintz, F, Krege, S, et al. Gender reassignment surgery: a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38:97-107.
Wilson, SC, Morrison, SD, Anzai, L, et al. Masculinizing top surgery: a systematic review of techniques and outcomes. Ann Plast Surg.
2018;80(6):679-683.The authors identify eight masculinizing top surgery studies to compare techniques and outcomes of gender-affirming mastectomy.
They report the most common technique as “inframammary fold skin excision with free nipple grafting” (42%), corresponding to a significantly less
acute reoperation rate compared to other gender mastectomy techniques; the highest rate of secondary operations occurred highest in the periareolar skin
resection cohort (37.5%). Satisfaction outcome measures were assessed using four studies. High satisfaction rates were consistent in all studies with
little variation after accounting for surgical technique.
Argalious, MY, You, J, Mao, G, et al. Association of testosterone replacement therapy and the incidence of a composite of postoperative in-
hospital mortality and cardiovascular events in men undergoing noncardiac surgery. Anesthesiology. 2017;127(3):457-465.A major source of
contention in current surgical practices involves stopping hormone replacement therapy (HRT) in transmasculine men prior to surgery. This is not
addressed in the WPATH SOC guidelines, and many patients are reluctant to stop testosterone due to undesirable side-effects. This study analyzes the
instances of in-hospital mortality and cardiovascular events between patients who are and are not on HRT. Their report of nearly 50,000 patients
(∼1,000 on testosterone) does not indicate a significant association between preoperative testosterone use and an increased incidence of postoperative
mortality and/or cardiovascular events, underscoring the need to re-evaluate the risks associated with stopping HRT prior to transmasculine gender-
affirming surgery.
Ammari, T, Sluiter, EC, Gast, K, Kuzon, WM. Female-to-male gender-affirming chest reconstruction surgery. Aesthet Surg J. 2018.
doi:10.1093/asj/sjy098. [Epub ahead of print].
Donato, DP, Walzer, NK, Rivera, A, Wright, L, Agarwal, CA. Female-to-male chest reconstruction: a review of technique and outcomes. Ann
Plast Surg. 2017;79(3):259-263.
Cregten-Escobar, P, Bouman, MB, Buncamper, ME, et al. Subcutaneous mastectomy in female-to-male transsexuals: a retrospective cohort-
analysis of 202 patients. J Sex Med. 2012;9:3148-3153.
Monstrey, S. Penile reconstruction with the radial forearm flap: an update. Handchir Mikrochir Plast Chir. 2011;43:208-214.
Monstrey, S, Hoebeke, P, Selvaggi, G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg.
2009;124(2):510-518.The authors describe the results of a large-volume (287) gender-affirming phalloplasty patient series of one surgical team. Their
main findings indicate that the radial forearm flap provides the best and most reliable outcome, though no technique fully satisfies construction of an
aesthetically pleasing, sensate, and functional neophallus. This overview suggests that a two-stage technique provides the most satisfactory results,
though high complication rates, scarring, and lack of long-term follow-up has yet to be eliminated with any existing technique.
Garaffa, G, Christopher, NA, Ralph, DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57(4):715-722.
Zuo, KJ, Roy, M, Meng, F, Bensoussan, Y, Hofer, SOP. Aesthetic and functional outcomes of radial forearm flap donor site reconstruction
with biosynthetic skin substitutes. J Plast Reconstr Aesthet Surg. 2018;71(6):925-928.
Salgado, CJ, Fein, LA, Chim, J, et al. Prelamination of neourethra with uterine mucosa in radial forearm osteocutaneous free flap phalloplasty
in the female-to-male transgender patient. Case Rep Urol. 2016;2016:8742531.
Hoebeke, PB, Decaestecker, K, Beysens, M, et al. Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur Urol.
2010;57(2):334-340.
Scherzer, ND, Dick, B, Gabrielson, AT, et al. Penile prosthesis complications: planning, prevention, and decision making. Sex Med Rev. July
19, 2018. pii: S2050-0521(18)30055-6. doi:10.1016/j.sxmr.2018.04.002. [Epub ahead of print].
Frey, JD, Poudrier, G, Chiodo, MV, Hazen, A. A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male
transgender genital reconstruction: is the “ideal” neophallus an achievable goal? Plast Reconstr Surg Global Open. 2016;4(12):e1131.
Morrison, SD, Shakir, A, Vyas, KS, et al. Phalloplasty: a review of techniques and outcomes. Plast Reconstr Surg. 2016;138(3):594-615.
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index
Note: Page numbers followed by “f” indicate figures and “t” indicate tables.
Abbe flaps, 410–411, 412f, 414
Abdomen-based flaps, 601–603, 603f–606f
Abdominal wall
implants, 82, 83f
muscle groups, 635
sensory nerves, 635, 636t
transplant, 970
vascular perfusion, 635
Abdominal wall reconstruction
anatomy
muscle/fascia, 966, 966f
nerve, 966
vascular, 966–967
bulge, 965
diagnosis
history, 967
physical exam, 967
diastasis recti, 965
emergency vs. elective surgery, 967–968
hernia, 965
mesh, 968–970
repair technique, 970
pathophysiology
extrinsic factors, 967
intrinsic factors, 967
technical factors, 967
patient-centered outcome tools
quality of life scales, 968
registries, 968
risk analysis, 968
and trunk hernias, 965, 965t
Abdominoplasty, 633
complications, 638
marking, 636
operative options and techniques
fleur-de-lis technique, 637, 637f
high lateral tension, 636
lipoabdominoplasty, 637
miniabdominoplasty, 636
traditional abdominoplasty, 636, 
 637f
patient selection and evaluation, 636
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pertinent anatomy, 635–636, 636t
positioning, 636
postoperative care, 637
safety, 636
scar management, 637
Abductor digiti minimi (ADM), 789
Abductor pollicis longus (APL), 780, 787
Ablative fractional laser therapy, 220
Ablative lasers, 466
Absolute difference, 155
Acellular dermal matrix (ADM), 476, 559, 590–591, 591f, 612, 823
submuscular reconstruction, 592
two-stage reconstruction, 592
Acetaminophen, 691
Acinic cell carcinoma, 361
Acne, 171–172
scars, 220
Acute cutaneous toxicities (ACT), 209
Acute forearm compartment syndrome, 
 899, 899f
Acute ischemia
iatrogenic, 876–877, 876f–877f
thromboembolism, 877
traumatic, 876
venous thrombosis, 877
Acute rejection, 68
Acute thumb MCPJ ulnar collateral ligament injuries, 802–803, 803f
Adductorplasty, 792
Adductor pollicis (AdP), 665
Adequate wound debridement, 820, 820f
Adipose tissue, 632, 653
Adjunctive liposuction, 653
Adjuncts, 590
Adjustable gastric band (AGB) procedures, 629
Adjustment, 161
Adjuvants, 21
Adjuvant therapy, 593f
indications, 593
previous radiation treatment, 594
salivary gland tumors, 362
systemic therapy, 594
technical aspects, 593–594
timing, 593
upper aerodigestive tract (UADT) cancers, 359
ADMSeeAcellular dermal matrix (ADM)
Adult stem cells, tissue engineering, 114
Advanced rhinoplasty maneuvers, 534
Advanced Trauma Life Support (ATLS), 819
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Advanced wound therapy, 54
Advertising, 141
Aeromonas hydrophila, 45, 836
Aesthetic facial skeletal augmentation, 546
Aesthetic problems, scar, 19
Aesthetic rhinoplasty, 525
Aesthetic surgery
external influences, 129
patient perspectives
bipolar personality disorder, 129
body dysmorphic disorder, 128
confounding factors, 128
expectations, 128
goals, 128
personality disorders, 128
psychiatric disorders, 128
physician perspective
adversarial patients, 129–130
adverse outcomes, 129
litigious patients, 129–130
AHSQC ORACLE, 968
Airway, breathing, and circulation (ABCs), 177–178
Alcohol, 575
Allen’s test, 867
Allergenicity, local anesthesia, 104
Allergy testing, rhinoplasty, 523
Alloplastic (implant) augmentation
complications, 548
limitations, 549
Alloplastic materials, 367, 369t
Alopecia, 172
Alpha, 155
Alveolar cleft closure, 235
Amastia, 616
Amazia, 616
Ambulation, 137
American Board of Plastic Surgery Code of 
 Ethics, 141t
American Dietetic Association (ADA), 627
American Joint Committee on Cancer (AJCC), 584
American Society for Aesthetic Plastic Surgery, 651
American Society for Metabolic and Bariatric Surgery, 651
American Society for Surgery of the Hand (ASSH), 906
American Society of Plastic Surgeons (ASPS), 121
American Society of Plastic Surgeons Code of Ethics, 141t
American Society of Plastic Surgeons Venous Thromboembolism Task Force, 633
, 634
American Spinal Injury Association (ASIA) Impairment Scale, 719, 720f
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Americas Hernia Society Quality Collaborative (AHSQC), 968
Amniotic band syndrome, 911
Amputated ear
banking of ear cartilage, 318
Baudet’s fenestration techniques, 318
Mladick’s pocket principle, 318
replantation, 318
AmputationSee alsoHand and upper extremity
avulsion amputation, 828, 829f
combined amputation, 828, 829f
destruction of TM joint
pollicization, 851
second-toe transfer, 851–852
Dupuytren disease (DD), 863
free nipple graft
operative technique, 571–572, 571f–572f
preoperative markings, 571, 571f
guillotine amputation, 828, 829f
metacarpal but with preserved TM joint
microsurgical techniques, 851
nonmicrosurgical techniques, 851
proximal phalanx with preserved MP joint
microsurgical reconstruction, 850–851
nonmicrosurgical techniques, 850
reconstructive surgery, 130
replantationSeeReplantation
Analysis of the Variance (ANOVA), 150, 158–159
Analytic plan, research studies
assigning variables, 148–149, 148t
conceptual model, 148
variable types, 148
Anatomic-shaped implants, 592
Ancillary tests, 672
Androgens, 575
Anesthesia, 44
“cosmetic” problem, 538
eyelid operative technique, 505
facelifting, 512
hand and upper extremity, 830
microsurgery, 44
regional anesthesia, 104–109
in rhinoplasty, 526
topical anesthesia, 104
Aneurysm, 879–880, 880f
Angiogram
aneurysm, 879, 880f
scleroderma, 878, 879f
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Angiography, 876
Angiosarcoma, 583
Angiosomes, 25
Ankle reconstruction, 984t
Anterior interosseous nerve (AIN), 692–693, 698
Anterior superior iliac spine (ASIS), 635
Anterior thoracic hypoplasia, 621
Anterolateral thigh (ALT) flap, 4
Anterolateral thigh perforator flap, 61
Antiandrogens, 575
Antibiotics, 596, 672
skin preparation, 136–137
Anticoagulation therapy, 835
Antipsychotics, 575
Antiretrovirals, 575
Apert syndrome, 266, 267f, 907–909
Apical ectodermal ridge (AER), 906
Areola reconstruction
prosthetics, 613
skin-grafting techniques, 612
tattooing, 613
Arm
flexion and extension, 663
liposuction, 634
Aromatase inhibitors, 585
Arterial ulcers, wound healing, 12
Arteriovenous malformations, 250, 250f, 
 251t
Arthritis, 690
Arthritis mutilans, 934
Arthrodesis, 863, 941
Arthroplasty, 939
Aspirin, 835
Asymmetry, 572
Athelia, 616
Aufricht retractor, 528
Augmentation mammoplastySeeBreast augmentation (BA)
Augmentation mastopexy, 657–658, 658f
Auricular blockade, 107
Authorship, 164
Autologous autoaugmentation, 657
Autologous flap techniques, 367–368See alsoBreast reconstruction
flap and donor site complications, 605
free flapsSeeFree flaps
monitoring, 605
pedicled flaps
latissimus dorsi (LD) myocutaneous flap, 601, 601f–602f
pedicled TRAM flaps, 601
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postoperative free flap care, 605
preoperative evaluation
breast cancer treatment plan, 
 599, 599f
history and exam, 600
perforator and pedicle evaluation, 600–601, 600f
timing, 599–600
recipient vessels, 604–605
Autologous tissue, 621
Autosomal inheritance pattern, 911
Avulsion amputation, 828, 829f, 848, 848f
Axilla and upper/middle back contouring
marking, 658
planning, 658
preoperative evaluation, 658
surgical technique, 658–659, 658f–659f
Axillary brachial plexus, 830
Axillary elliptical incisions, 653
Axillary hyperhidrosis, 484
Axillary lymph node dissection (ALND), 585
BASeeBreast augmentation (BA)
Babysitter nerve transfers, 699
Baker classification system, 558–559, 558t
Bariatric surgery
vitamins and elements, 628, 628t
Basal cell cancer (BCC), 208
Basal cell carcinoma, 173
Base width (BW), 555, 556f
BCTSeeBreast conservation therapy 
 (BCT)
Belt lipectomy
complications, 639
marking, 638, 639f
patient selection and evaluation, 638
pertinent anatomy, 638
positioning, 638
safety, 638
technique, 639
Benign lesions, skin
acne, 171–172
alopecia, 172
contact dermatitis, 170, 170f
eczema, 170
hair disorders, 172
hyperpigmentation, 172
hypopigmentation, 172
nail disorders, 172
nevi, 170
psoriasis, 171, 172f
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rosacea, 170
seborrheic dermatitis, 170–171
urticaria, 171
Bennett fracture, 735, 736f
Bent finger, 910
Beta, 155
Betamethasone, 779
Bias, 155
Bicalutamide monotherapy, 577
Bicondylar fractures, 732
Bilateral cleft lip, 228–229, 231
Bilateral gynecomastia, 622, 623f
Bilateral type III tuberous breast, 616, 616f
Biofilm-infected chronic wounds, 13
Biologic fillers
autologous biologic fillers, 474
nonautologous biologic fillers, 474–476
Bioprosthetic mesh, 951
Biopsy, 240
suspected malignant tumors, 868
Bipolar personality disorder, aesthetic surgery
diagnosis, 129
epidemiology, 129
management, 129
Birth-related brachial plexus palsies (BRBPP), 702–703, 702f
Bleeding, 576
Blepharoplasty
anatomy, 500–502, 501f–504f
complications, 507–508
lower lid techniques
anesthesia, 506
markings, 506
shields, 506
transconjunctival approach, 507
transcutaneous approach, 506
operative technique, 505
outcomes, 508
periorbital aging, 500
postoperative care, 507
preoperative evaluation, 502–505, 504f, 
 505t
upper lid techniques
anesthesia, 505
fat removal, 506
lacrimal gland, 506
markings, 505, 506f
muscle resection, 506
skin closure, 506
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skin resection, 506
Block sampling, 148
Blood monitoring, 137
Blood supply, flaps, 25, 26f
Bodybuilders, gynnecomastia, 579
Body contouring operations, 633
Body dysmorphic disorder, aesthetic surgery
diagnostic principles, 128t
epidemiology, 128
impact, 128
management, 128
presentation, 128
Body mass index (BMI), 628, 651See alsoBariatric surgery
Body-powered prostheses, 921
Bone
allograft, 71
altered kinematics, 808
dyssynchronous motion, 808
fixation method, 832, 833f
resorption, 548
rhinoplasty, 519
tissue engineering, 117
Botulinum toxin
adverse effects, 485
clinical applications
axillary hyperhidrosis, 484
brow elevation, 484
chronic migraines, 485
facial rhytids, 483
forehead, 484
glabella, 483–484, 483f
gummy smile, 484
hypertrophic scarring, 485
lateral canthal region, 484
nasolabial fold, 484
neck, 484
upper extremity vasospastic disorders, 485
commercial preparations, 482
contraindications, 485
history, 481
lateral epicondylitis, 779
mechanisms, 481–482
pharmacology, 481–482
scar management, 20
structure, 481–482
warnings, 485
Brachial plexus injuries
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anatomic classification, 709t
Alnot classification of preganglionic root, 706
Chuang’s level 1 to 4 classification, 706
postganglionic root, 706
supraclavicular and retroclavicular, and infraclavicular injuries, 706
supraclavicular postganglionic, and infraclavicular injuries, 706
Terzis’ three-level system of root, 706
variability in frequency, 707
anatomy, 706, 707f
epidemiology, 706
history and examination
anterior shoulder dislocation and scapular fracture, 707
deafferentation pain, 708
electrodiagnosis, 709–710, 711t
Hoffmann-Tinel sign, 708
Horner syndrome, 708
radiographic imaging, 708–709
spine fractures, 707
worksheet, 708, 710f
multidisciplinary approach, 713–714
nerve injury classification, 707, 709f
obstetric brachial plexus palsy (OBPP)
hallmark stigmata and primary challenge, 715
injury patterns, 714, 715t
interventions, 715
protective factors, 714, 715t
risk factors, 714, 715t
outcomes, 715
surgical treatment
biomechanical restorative approach, 711, 713, 713t–714t
distal (close target) nerve transfers, 711, 712, 712t–713t
functioning free muscle transplantations (FFMTs), 711
proximal exploration and reconstruction, 711
reconstructive options, 711, 712t
timing, 707, 710f
Brachioplasty
classification, 651
complications, 654–655
extended, 653–654, 654f–655f
liposuction, 653
marking, 653
massive weight loss upper torso deformity, 651, 652f
minibrachioplasty, 653, 653f
outcomes, 654–655
planning, 653
postoperative management, 654–655
preoperative evaluation, 653
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related anatomy, 652–653
type III patients, 652
type II patients, 652
type I patients, 652
Brachioradialis (BR), 721
Brand flexor carpi radialis tendon transfer for ulnar nerve palsy, 792, 793f
BRCA 1, 583
BRCA 2, 583
Breast
ectodermal plaques, 615
enlargement, 575
innervation, 655
maleSeeGynecomastia
parenchyma, 559
photography, 121, 122f
ptosisSeeBreast ptosis
symmetry, 595
tissue expanders, 616
tissue expansion, 101
Breast augmentation (BA), 1023, 1023f
implants
anatomic, 557
complications, 558–559, 558t
incisions and planes, 557–558, 557f–558f
macrotextured devices, 557
outer shell, 557
silicone, 557
textured devices, 557
preoperative assessment
grades of breast ptosis, 556, 556f
inframammary fold (IMF), 555
key landmarks and measurements, 555, 556f
magnetic resonance imaging (MRI), 556
natural look, 555
nipple-areola complex (NAC), 555
pectoralis muscle, 556
ultrasound (US), 556
Breast cancer, 207
axillary lymph node dissection (ALND), 585
biologic therapy, 585
breast conservation therapy (BCT), 584
breast reduction, 573
cancer therapies before and after surgery, 585
contralateral prophylactic mastectomy, 584
hormonal blockade, 585
in males, 576
mastectomy, 584
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neoadjuvant systemic therapy, 584
radiation therapy, 585
risk factors, 583
screening, 584
surgical treatment, 584
systemic therapy, 585
TNM staging system, 584
treatment plan, 599, 599f
types, 583
work-up, 584
Breast Cancer Risk Assessment Tool, 583
Breast conservation therapy (BCT), 584
Breast contouring, 656f
anatomy, 655–656
augmentation mastopexy, 657–658, 658f
autologous autoaugmentation, 657
breast reduction, 656
marking, 656
mastopexy, 656–657, 657f
planning, 656
preoperative evaluation, 656
Breastfeed inability, 572
Breast hypoplasia, 616, 616f
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), 558
Breast implants
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), 82
capsular contracture, 82
placement options, 557, 557f
polypropylene, 82
tabbed tissue expander, 82, 82f
vicryl mesh, 82
Breast ptosis, 556, 556f, 656
Breast reconstruction, 130, 196–197
autologous flap techniques
flap and donor site complications, 605
free flaps, 601–604
monitoring, 605
pedicled flaps, 601–604
postoperative free flap care, 605
preoperative evaluation, 599–601
recipient vessels, 604–605
prosthetic techniquesSeeProsthetic reconstruction
Breast reduction, 656
acute complications
delayed wound healing, 572
hematoma, 572
seroma, 572
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vascular compromise, 572
amputation/free nipple graft
operative technique, 571–572, 571f–572f
preoperative markings, 571, 571f
anatomy and physiology, 564
history, 564
inferior pedicle technique, 566
medial and lateral flaps, 568
nipple-areolar complex position, 568
preoperative markings, 567, 568f
suction-assisted lipectomy (SAL), 567
upper flaps and suturing, 568, 568f
long-term complications
asymmetry, 572
breast cancer, 573
fat necrosis, 572
fibrosis, 572
high NAC position, 573
hypertrophic scarring, 573
inability to breastfeed, 572
inverted nipples, 572
nipple areolar sensation, 572–573
physical examination
areola, 565
breast parenchyma, 565
costal margins, 565
deficient cephalic and medial breast, 564
IM fold asymmetries, 564
intertrigo, 564
macromastia, 565f
manubrial projection, 564
nipple-areolar complex (NAC) position, 565
papule, 565
pectus carinatum, 564
pectus excavatum, 564
scoliosis and chest wall asymmetries, 564
shoulder grooving and hyperpigmentation, 564
skin quality, 564
soft tissue fullness, 564
stature, 564
potential complications, 572, 573f
preoperative markings
flexible wire keyhole template, 566
inframammary (IM) fold, 565, 566f
intended breast meridian, 566, 566f
medial and lateral limbs, 566
nipple position, 566, 567f
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normative values, 566, 567t
preoperative photography, 565, 566f
suction-assisted lipectomy, 572
superomedial pedicle technique, 569, 569f–570f
vertical skin resection, 570
Bridging therapy, 54f
Brow
forehead
aging, 494–496, 496f–497f
anatomy, 493–494
fat, 494
history, 493
Brow elevation, 484
Brown-Séquard syndrome, 719
BRBPPSeeBirth-related brachial plexus palsies (BRBPP)
Bruner incisions, 674
Buccal and retromolar trigone reconstruction
flap choices, 444–445
goals, 444
Buccal fat pad flaps, 234
Buccal nerve transfer, 699, 700f
Buerger disease, 880
Bulge, 965
Burn depth determination, 178, 178f
Burned hand
reconstruction, 890–891
recovery, 891, 892t
amputations, 892
condition of skin, 892
digits, 892
nerve injuries, 892
range of motion, 892
rehabilitation, 888–890
resurfacing, 887
crush injury from industrial press, 888, 889f
diabetes and rheumatoid arthritis, 888, 890f
fourth-degree burn wounds, 888, 891f
full-thickness burn injury, 888, 888f
resuscitation, 887f
damage control approach, 886
wound care, 887
Burn reconstruction
breast reconstruction, 196–197
burn scarsSeeBurn scars
canthi, 191–192, 193f
cheek reconstruction, 194–196, 195f
chest reconstruction, 196–197
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ear reconstruction, 194, 195f
face, 191
hand reconstruction, 198–200, 198f–200f
lower extremity, 197–198, 197f
lower lid, 191
nasal reconstruction, 193–194, 194f
neck reconstruction, 196
perioral reconstruction, 192–193
periorbital reconstruction, 191
principles, 189–200
scalp reconstruction, 193
upper lid, 191, 192f
Burns
chemical burns, 184
cold injuries, 185
electrical burns, 185
epidemiology, 177
management
airway, breathing, and circulation (ABCs), 177–178
burn depth determination, 178, 178f
burn size, 178–180, 179f
patient triage, 180, 180t
survivable injuries, 180
Burns (Continued)
pathophysiology, 177
burn shock, 177
local, 177
resuscitationSeeResuscitation
special anatomic considerations
face, 185–186, 186f
hands, 186
neck, 186, 186f
surgical management
communication, 183
debridement, 183
dressings, 184
graft placement, 184
graft selection, 184
hemostasis, 183
indications, 183
occupational therapy, 184
operative planning, 183
physical therapy, 184
skin substitutes, 184
wound bed preparation, 183
wound closure, 183–184
Burn scars, 189, 190f, 220
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contractures, 191–200
flaps, 190–191
grafted skin, 190–191
local tissue rearrangement, 190
site-specific surgical interventions, 191–200
skin graft, 190
timing, 189
tissue expansion, 190–191
Calcineurin inhibitors, 69
Calcium hydroxylapatite (CaHA), 476
Calvarium
anatomy, 365
reconstruction, 367–371, 369t, 370f
alloplastic materials, 367, 369t
autologous techniques, 367–368
composite tissue allograft transplantation, 370–371, 370f
infected cranioplasty, 369–370
Camitz transfer, 789
Camptodactyly, 910
Candida albicans, 673
Cannabinoids, 714
Canthal reconstruction
lateral canthal reconstruction, 387
medial canthal reconstruction, 386–387, 
 387f
Canthi, 191–192, 193f
Canthoplasty, 391
lateral tarsal strip, 390–391, 390f
outcomes, 391
prognosis, 391
tarsal tuck canthopexy, 390
treatment, 389–390
Capillaroscopy, 876
Capillary malformations, 249
Capsular contracture
Baker classification system, 558–559, 558t
etiology, 558
grade III, 558
grade IV, 558
implant-based reconstruction, 595, 595f
Capsulectomies, 99
Cardiovascular system (CVS), 106
Carolinas comfort scale, 968
Carpal derangement, 808
Carpal instability, 808
adaptive, 808
complex, 808
nondissociative, 808
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Carpal instability dissociative (CID), 808
Carpal tunnel syndrome (CTS), 691
anatomy, 691
diagnosis, 691, 691f
etiology, 691
nonoperative treatment, 691–692
operative treatment, 692
Carpometacarpal joint, 663, 722
Carroll test, 916
Cartilage allograft, 71
Cartilage grafts, 3
Cartilage-splitting incision, 527
Cartilage, tissue engineering, 117
Cartilage xenograft, 71–72
Categorical variables, 148, 155
Caudal septal modification, 530
Cauliflower ear, 318
Cell cultured products, 15
Cell-material hybrids, 113, 114f
Cellular dermal matrix, 590
Cellulitis, 674, 674f
Central nervous system (CNS), 106
Central slip injuries, 800
Cephalometrics, 289, 289f
Cephalosporin, 672
Cerebrospinal fluid (CSF), 270
Cervical lymphadenectomy
salivary gland tumors, 362
upper aerodigestive tract (UADT) cancers, 358–359
CFMSeeCraniofacial microsomia (CFM)
Charcot-Marie-Tooth, 693
Cheek
anatomy, 414–415
zygomatic ligaments, 415
Cheek reconstruction, 194–196, 195f
free tissue transfer, 417
healing by secondary intention, 415
local tissue rearrangement, 415
options, 415–417
preoperative considerations, 414
primary closure, 415
regional flaps, 415, 416f
skin grafts, 415
tissue expansion, 417
Cheiralgia paresthetica, 694
CHEK2, 583
Chemical burns, 184
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Chemical injuries, 177–186
Chemical peels, 168
Chemosis, 507
Chest reconstruction, 196–197
Chest wall
anatomy, 949
musculoskeletal, 950f
asymmetries, 564
etiology, 949, 950f
implants, 82
patient selection, 950
physiology, 949
preoperative planning, 950
skeletal reconstruction, 952f
bioprosthetic mesh, 951
indications, 950
latissimus-sparing thoracotomy, 951, 953f
materials used, 950, 951t
methylmethacrylate, 951
soft tissue reconstruction, 951–952, 953t, 954f
Chest X-ray, brachial plexus injuries, 708
Chin implant insertion, 548, 548f
Chi-square tests, 150
Chondroitin-6-sulfate, 54
Chromic suture, 540
Chronic inflammation, 12
Chronic ischemia
aneurysm and thrombosis, 879–880, 880f–881f
Buerger disease, 880
vasospastic disease, 877–879, 878f–879f
Chronic mallet injuries
Fowler tenotomy/central slip tenotomy, 769
skin imbrication/tenodermodesis, 769
spiral ORL reconstruction, 769, 770f
Chronic migraines, 485
Chronic nerve compression, 690
Chronic paronychias, 673
Chronic rejection, 68–69
Chronic thumb MCPJ UCL injuries, 803
Chronic wounds, 2, 12
tissue engineering, 116
Circumareolar mastectomy, 1025–1026
Cleft lip and palate, 229
bilateral cleft lip, 228–229
classification, 226–220, 227f
definition, 225
embryology, 225
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epidemiology, 225–226
isolated cleft palate, 229
microform cleft lip, 227, 228f
presurgical orthopedics, 229
spectrum, 226–220
submucous cleft palate, 229
surgical correction
alveolar cleft closure, 235
bilateral cleft lip, 231
buccal fat pad flaps, 234
cleft palate, 232, 232t
hard palate closure techniques, 232, 233f
orthognathic surgery, 235
secondary speech surgery, 234–235
soft palate closure techniques, 233, 234f
timing, 229
unilateral cleft lip, 229–231, 231f
surgical molding, 229
unilateral cleft lip, 227–228
Clindamycin, 672
Clinodactyly, 910–911, 911f
Clomiphene citrate, 577
Closed central slip injury, 771
associated avulsion fracture, 771
Closed hand fractures, 729
Closed rhinoplasty (basic), 526
dorsal elevation and reduction, 533–534
final inspection and closure, 534
osteotomies, 534
septoplasty, 534
spreader grafts and flaps, 534
tip cartilage-splitting method, 533
tip delivery method, 533
tip modification, 534
CMNSeeCongenital melanocytic nevi (CMN)
CO2 lasers, 466
Cohesive multidisciplinary approach, 950
Cold injuries, 185
Collagen, 474–475
Collagenase Clostridium histolyticum (CCH), 860–861
Collagenase injection, 860
Colles fascia, 647
Combined amputation, 828, 829f
Combined surgery, 659
Communication, 136
Compartment syndrome, 974
anatomy
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constitutes and contents, 895, 896t
dorsal compartment, 897
forearm, 895, 897f
upper arm, 895, 896f
chronic, 900
diagnosis
clinical signs, 899–900, 899f, 900t
compartment pressure measurement, 900, 901f
epidemiology, 895
etiology, 898–899, 898t
fasciotomy
compartments, 900, 902f
digital compartment release, 902, 903f
dorsal, 900, 902f
interossei and adductor compartments, 902, 903f
upper arm, 900, 901f
volar, 900, 902f
history, 895
outcomes and complications, 903, 903f
pathophysiology, 897–898, 898f
postoperative management, 902
treatment, 900–902
Competency, 142
Complete decongestive therapy (CDT), 1003
Complete dorsal dislocation, 802
Complex lower extremity reconstruction, 4
Complex regional pain syndrome (CRPS), 736, 747
Composite tissue allograft transplantation, 370–371, 370f
Compound chimeric flap, 33
Compression, scar management, 20
Compression screws, 730–731, 732f
Computed tomography (CT)
brachial plexus injuries, 708
deep-space infections, 675
liposuction, 632
rhinoplasty, 523
scaphoid fractures, 748
Computed tomography angiography (CTA), 600, 876, 978
Concomitant facial paralysis, 700
Condylar fractures, 732
Confidence interval (CI), 155
Confidence level, 155
Confidentiality, 140
Conflicts of interest, 141
Confounding, 161
Confounding variables, 149
Congenital anomalies, 101, 130
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Congenital anomalies of breast
anterior thoracic hypoplasia, 621
embryology, 615, 615f
hyperplastic disorders, 621–624
hypoplastic disorders, 616, 616f
Poland syndrome, 618–621
tuberous breast deformity, 618t
bilateral type III tuberous breast, 616, 616f
characteristics, 616
etiology, 616
Grolleau classification, 616, 617f
incidence, 616
surgical correction, 617–618
Congenital hand anomalies
camptodactyly, 910
cleft hand (central longitudinal deficiency), 913
clinodactyly, 910–911, 911f
constriction ring syndrome, 911–912
embryology, 906–907
polydactyly, 909, 909f
radial column (preaxial) abnormalities, 911
radial longitudinal deficiency (RLD), 912–913, 913f
symbrachydactyly, 909
syndactyly, 908f
Apert syndrome, 907–909
border digits, 907
classification, 907
skin deficiency, 907, 907f
timing of surgical intervention, 907
web creep, 907, 908f
timing of intervention, 906
Congenital hemangiomas, 248
Congenital melanocytic nevi (CMN)
classification, 238
dysplastic nevi, 240, 241f
dysplastic nevus syndrome, 240
epidermal nevi, 241–242, 242f
Halo nevi, 240, 240f
sebaceous nevi, 242, 242f
skin layers, 238
Spitz nevi, 238–240, 240f
surgical management, 240–241, 241f–242f
Consolidated Standards of Reporting Trials (CONSORT), 155
Constricted ear, 313–314, 314t
Constricted ears
mildly constricted ear, 541, 541f
moderately constricted ear, 541, 541f
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reconstruction, 541, 542f
Constriction band syndrome, 911
Constriction ring syndrome, 911–912
Contact dermatitis, 170, 170f
Continuous variables, 148, 155
Contractures, 191–200, 719
Contralateral defunctioning, facial paralysis, 425–427
Contralateral prophylactic mastectomy (CPM), 584, 588, 599
Control group, 155
Convenience sampling, 147
Conventional skin grafts, 52–53
Core suturing, 757, 758f
Corneal abrasion, 507
Corneal exposure, 507
Coronal craniosynostosis, 258, 259f
fronto-orbital advancement technique, 258, 261f
fronto-orbital distraction technique, 258–259, 261f
Corticosteroid injection
De Quervain disease, 780
lateral epicondylitis, 779
medial epicondylitis, 780
trigger finger, 781
Corticosteroids, 20, 69–70
Cosmetic laser resurfacing, 219
Count variables, 148
Cowden syndrome, 583
Cranial base, 277
Cranial reconstruction, 99f
Cranial vault distraction, 285
Cranial vault remodeling
fronto-orbital advancement (FOA), 269
posterior fossa distraction, 268–269
Craniofacial clefts
median craniofacial hypoplasia, 301–303
midline craniofacial dysraphia, 303–304
midline craniofacial hyperplasia, 304
number 1 cleft, 304
number 2 cleft, 304, 305f
number 3 cleft, 304–305, 305f
number 4 cleft, 305
number 5 cleft, 305, 306f
number 6 cleft, 305–306
number 7 cleft, 306, 307f
number 8 cleft, 306
number 9 cleft, 306, 307f
number 10 cleft, 306–308
number 11 cleft, 308, 308f
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number 12 cleft, 308
number 13 cleft, 308, 309f
number 30 cleft, 308, 311f
tessier classification, 301, 302t
treatment, 309–310
Craniofacial distraction
cranial vault distraction, 285
distraction osteogenesis, 285–286
hardware, 283–284, 284f, 284t
mandibular distraction, 284
monobloc distraction, 284
principle, 283
Craniofacial microsomia (CFM)
classification schemes, 278
definition, 276
ears, 278
epidemiology, 276
eye, 277–278
imaging and testing, 280
management, 280–282
pathophysiology, 276
presentation, 277, 277f
cranial base, 277
ears, 278
eye, 277–278
mandible, 277
maxilla, 277
nervous system, 277–278
orbit, 277–278
skin and soft tissue, 278
systemic, 278
zygoma, 277
treatment, 280–282
workup, 278
Craniofacial tumors
fibrous dysplasia, 329–330
Moebius syndrome, 335–337
neurofibromatosis, 332–335
Parry-Romberg syndrome, 330–331
Treacher Collins syndrome (TCS), 
 331–332
Craniosynostosis
nonsyndromes
anatomy, 255, 256f
complications, 261
diagnosis, 257–258
embryology, 255
epidemiology, 255
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operative management, 258–261
pathogenesis, 255–257
syndromes
Apert syndrome, 266, 266f–267f
clinical findings, 264, 265t
Crouzon syndrome, 264–266, 266f
Muenke syndrome, 266–267
Pfeiffer syndrome, 267
Saethre-Chotzen syndrome, 266, 268f
surgical management, 267–272
treatment outcomes, 272–273, 272t
Crepitation, 781
Cross-facial nerve grafting, facial paralysis, 429, 430f
Cross-finger flap, 849–850
Crouzon syndrome, 264–266, 266f
Crush injuries, 736
Cryolipolysis, 634
Cryopreservation, 611
Cryotherapy, scar management, 20
Cryptotia, 312–313, 539
otoplasty for, 541, 542f
C-shaped epiphysis, 910
CTSeeComputed tomography (CT)
CTASeeComputed tomography angiography (CTA)
CTSSeeCarpal tunnel syndrome (CTS)
Cubital tunnel syndrome
diagnosis, 693
etiology, 693
treatment, 693
Curved Joseph-Peck scissors, 528
Cutaneous flaps, 26
Cyanoacrylate glue, 540
Cysts
dermoid cysts, 243
epidermal cysts, 243
pilomatrixomas, 243
Damage control surgery principles, 916
Data cleaning activities, 163
Data collection, 162
Data dictionaries, 163
DDSeeDupuytren disease (DD)
Deafferentation pain, 708
Debridement, 14
mutilating upper extremity injuries, 820, 820f
Decision-making capacity, 142
Deep circumflex iliac artery (DCIA), 434–435, 436f
Deep inferior epigastric flaps, 59–60
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Deep palmar arch, 875, 875f
Deep-space infections, 675, 675f
Deep vein thrombosis prophylaxis, 136
Defect assessing, flaps, 31–32
Deformational plagiocephaly, 256–257, 257f, 257t
Delayed replantation, 829
Delayed wound healing, 572
Delta phalanx, 910
Deltoid function, 701
De Quervain disease, 780–781, 780f
Dermal-epidermal grafting, 53
Dermal fillers
adverse events, 476–477
biologic fillers
autologous biologic fillers, 474
nonautologous biologic fillers, 474–476
hypersensitivity reactions, 477
indications, 472
injectable fillers, 473–476, 474t
injection techniques, 473
nodule formation, 477
patient selection, 472–473
scarring, 477
skin necrosis, 477
superficial filler placement, 476
synthetic fillers, 476
vision loss, 477
Dermal replacement, 21
Dermal substitutes, 680
Dermal suspension techniques, 656
Dermofasciectomy, 862
Dermoid cysts, 243
clinical findings, 336
complications, 337
definition, 336
etiology, 336
pathogenesis, 336
treatment, 337
Dexamethasone, 779
Dextran 40, 835
Diabetes, 589, 978
Diabetic foot ulcers, 12
Diaphragmatic function, 708
Diaphragmatic muscle paralysis, brachial plexus injuries, 708
Diastasis recti, 965
Dichotomous variables, 148, 155
Digit, 668, 668f
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Digital amputation, 917, 918f
Digital extensor tendon excursion, 766
Digital replantation in children, 829
Digits
amputation, 829
hand fractures, 729, 729f
hand infections
felon, 673, 673f
flexor tenosynovitis, 673–674, 673f
paronychia, 673
Diplopia, 508
Direct closure, 21
Direct excision techniques, 1004, 1004f
Direct-to-implant approach, 590
Discrete variable, 155
Diseased fascial cords, 859, 859f
Distal digital replantation
guillotine-type amputation, 835, 836f
impossible vein repair, 835
medicinal leech, 836, 837f
procedure, 835
Distal humerus Marquardt angulation osteotomy, 920, 921f
Distal interphalangeal joint (DIP), 667, 859
Distal phalanx, 731–732, 733f–734f
Distal ports, 98
Distal radioulnar joint (DRUJ), 663, 747
instability, 747
Smith fractures, 744
and tensions, 740
Distal radius fractures
anatomy, 740
biomechanics, 740–741
classification
dorsal ulnar corner, 741
eponyms used, 741, 742f
intra-articular distal radius fractures, 741, 742f
radial column, 741
volar rim/lunate facet, 741
complications, 747
distal radioulnar joint instability, 747
epidemiology and cost, 740
intercarpal ligament injuries, 747
median nerve dysfunction, 747
operative treatment
associated injuries, 744
fracture pattern, 744
fracture stability, 744
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patient factors, 742–744
outcomes assessment, 748
radiographic evaluation, 741–742, 743f
rehabilitation, 748
treatment modalities
closed reduction and percutaneous pinning, 745
closed reduction and plaster immobilization, 744, 744t, 745f
dorsal plating, 745
external fixation and bridge plating, 746, 747f
fragment-specific fixation, 745–746, 746f
volar locking plate fixation, 745, 745f–746f
ulnar styloid injuries, 747
Distal revascularization with interval ligation (DRIL), 877
Distant pedicle flaps, 684
Distraction lengthening, 850
Distraction osteogenesis, 268, 285–286
Documenting organization utility, 164
Donor site, 51–52
flaps
content selection, 32
management, 33
manipulation, 33
pedicle considerations, 33
site selection, 32
morbidity, 3–4
Doppler ultrasound, 821
Dorsal block K-wire fixation, 731
Dorsal hand
distant pedicle flaps, 684
flap selections, 683, 683t
free fasciocutaneous flaps, 684
free/pedicle fascial flaps, 684
lateral arm flaps, 684
Lister’s tubercle, 667, 667f
medium-sized defects, 683
superficial circumflex iliac perforator (SCIP) flaps, 684
Dorsal intercarpal ligament (DIC), 808
Dorsal metacarpal artery (DMCA) flap, 681
Dorsal plating, 745
Dorsal soft tissue loss, 848
Dorsal V sign, 798, 799f
Double crush phenomenon, 690
Doxycycline, 672
Doyle classification of mallet injury, 767, 769t
Drains, 596
Drug abuse, 677
Dry eye, 507
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Ductal carcinoma in situ (DCIS), 583
Dumping syndrome, 628
Duplex ultrasonography, 876
Dupuytren contracture, 19
Dupuytren disease (DD), 859
Dupuytren diathesis, 859, 860t
epidemiology, 858
history, 858
nature vs. nurture, 858
outcomes, 863–864
pathophysiology
involutional stage, 859
proliferative stage, 859
residual stage, 859
patient evaluation, 860
prevalence, 858
risk factor, 858
treatment
adjunctive procedures, 862–863, 863f
minimally invasive options, 860–861, 861f
nonsurgical options, 860, 860t
salvage procedures, 863
surgical options, 861–862, 861f–862f
Dupuytren tissue, 859
Durable power of attorney for health care (DPOA-H), 142
Dynamic fluorescent angiography, 876
Dysplastic nevi, 240, 241f
Dysplastic nevus syndrome, 240
Ear abnormalities, 538
Early protected motion (EPM), 835
Ear molding, 314
commercially available system, 539, 539f
wire and tape, 539, 539f
Ear reconstruction, 194, 195f
amputated ear, 318
anatomy, 312
cauliflower ear, 318
constricted ear, 313–314, 314t
cryptotia, 312–313
dimensions, 312
ear molding, 314
embryology, 312, 312f
location, 312
microtia, 314–317
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partial auricular defect, 317–318
stahl ear, 313
Ectopic transplantation, 829
Eczema, 170
Edwardsiella tarda, 676
Effect modification, 161
Elbow
disarticulation, 920
extension, 701
reconstruction
restoration, 723–724, 724f
tendinopathy, 778
Elective surgeries, 1
Electrical burns, 185
Electrical injuries, 177–186
Electromagnetic therapies, 15
Electromyography, 690
Elson test, 770, 771f
Embryonic mammary ridges, 615, 615f
Embryonic stem cells, tissue engineering, 
 114–115
Enchondromas, 871–872, 872f
End organ perfusion, local anesthesia, 106
End-to-end anastomosis, 42
Epidermal cysts, 243, 871, 871f
Epidermal grafting, 53
Epidermal inclusion cysts, 871, 871f
Epidermal nevi, 241–242, 242f
Epidermal nevus syndrome, 241
Epinephrine, 691, 830
Epinephrine infiltration, local anesthesia, 106
Epiphora, 508
Epitendinous sutures, 758
Epitenon, 755
Erbium-yttrium-aluminum-garnet laser, 466–467, 467f–468f
Error disclosure, 140
Erysipelothrix rhusiopathiae, 676
Erythema, 781
Esophageal reconstruction, 453–454
esophageal and tracheal resections, 454
Estrogens, 539, 615
Ethics, plastic surgery
advertising, 141
American Board of Plastic Surgery Code of Ethics, 141t
American Society of Plastic Surgeons Code of Ethics, 141t
confidentiality, 140
conflicts of interest, 141
error disclosure, 140
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informed consent, 141–142
operating on family members, 140
privacy, 140
professionalism, 140
relationships with industry, 141
social media, 141
truthfulness, 140
Excision
dermal replacement, 21
direct closure, 21
flap closure, 21
ganglions, 869
grafting, 21
skin grafting, 21
W-plasty closure, 21
Z-plasty closure, 21
Excision-site liposuction, 648
Excursion of donor muscle, 786
Experimental group, 155
Extended brachioplasty
anterior incision, 654
inferior incision, 654
liposuction, 654, 655f
markings, for upper body lift, 654, 654f
segmental excision, 654, 655f
Extensor carpi radialis brevis (ECRB), 701, 721, 763, 787
Extensor carpi radialis brevis adductorplasty, 792, 792f
Extensor carpi radialis longus (ECRL), 722, 763
Extensor digiti minimi (EDM), 763
Extensor digitorum communis (EDC), 665, 722, 763
Extensor indicis proprius (EIP), 665, 763, 789, 790f
Extensor pollicis brevis (EPB), 721, 780
Extensor pollicis longus (EPL), 701, 721, 764
Extensor tendon repair and reconstruction, 768f
clinical anatomy and function, 763, 764f
clinical assessment, 767
digital extensor system, 765–766
extrinsic system, 765f
extensor digiti minimi (EDM), 763
extensor digitorum communis (EDC), 763
extensor indicis proprius (EIP), 763
extensor pollicis longus (EPL), 764
finger extensor apparatus, 763, 766f
hand and wrist, 763, 765t
retropulsion, 764, 766f
surgically relevant anatomical pearls, 764, 767t
thumb extension, 764
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function, 766–767, 768f
injury patterns, 767
intrinsic system, 764–765, 768f
repair and rehabilitation, 767
thumb, 773–774, 774
zone 1
chronic mallet injuries, 769
Doyle classification of mallet injury, 767, 769f
posttraumatic swan-neck deformity, 769
splinting, 768
swan-neck deformity, 767
type I (closed) bony mallet finger, 767, 769f
type II (open) mallet finger, 768, 770f
zone 2, 770, 771f
zone 3
boutonnière deformity, 770, 771f
closed central slip injury, 771
closed central slip injury with associated avulsion fracture, 771
Elson test, 770, 771f
open zone 3 injury, 771
posttraumatic boutonnière deformity, 771–772
zone 4, 772
zone 5, 772, 773f
zone 6, 772
zone 7, 772
zone 8, 772
zone 9, 773
External distractors, 3
External fixation, 731
Extra-articular metacarpal base fractures, 734
Extracellular matrix (ECM), wound healing, 10–12, 11f
Extracorporeal shock wave therapy (ESWT), 10, 13, 15
Extremities, tissue expansion, 101
Eyelid
anatomy, 381–382, 381f
blood supply, 383
conjunctiva, 382–383
fat pads, 382
lacrimal system, 383
lamellar structure, 381–382, 381f
lymphatics, 383
muscles, 382
orbital septum, 382
postoperative considerations, 383
preoperative considerations, 383
skin, 382
tarsoligamentous sling, 382
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Eyelid reconstruction
canthal reconstruction
lateral canthal reconstruction, 387
medial canthal reconstruction, 386–387, 387f
lower eyelid reconstruction
anterior lamella, 385
full-thickness defects, 385–386, 386f
outcomes, 386
partial-thickness defects, 385
prognosis, 386
ptosis
correction of eyelid, 387–389
frontalis sling, 389
levator advancement, 388–389
levator repair, 388–389
Müller muscle-conjunctiva resection, 
 388
outcomes, 389
preoperative evaluation, 387–388
prognosis, 389
upper eyelid reconstruction
anterior lamellar, 383–384
full-thickness defects, 384
outcomes, 384–385
partial-thickness defects, 383–384
prognosis, 384–385
Face
local anesthesia, 107, 107f
nerve transfers
motor, 699, 700f
sensory, 700, 700f
Facelifting
anatomy
fat compartments, 510
motor and sensory nerves, 510, 512f
retaining ligaments, 510, 511f
skin, 510
superficial musculoaponeurotic system (SMAS), 510
vascular supply, 510–511, 513f
anesthesia evaluation, 512
complications, 516
patient evaluation, 511
postoperative management, 516
techniques
fat grafting, 515
incisions, 512
skin-only lifts, 512
superficial musculoaponeurotic system (SMAS), 512–515, 514f
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Face reconstruction, 191
Face transplantation, 73–74
Facial bipartition, 271–272
Facial feminization
female facial morphology, 1021
forehead, 1021
mandibular contour and lower face, 1021
midface, 1021
preoperative evaluation, 1021
Facial paralysis
anatomy, 420–422
background, 420
causes, 422–424, 424t
effects
lower face, 424–425
upper face, 424
extratemporal facial nerve, 420
facial nerve, 421, 422t, 423f
cervical division, 422
marginal mandibular division, 421–422
temporal division, 421
zygomatic and buccal division, 421
functional components, 420
intracranial facial nerve, 420
intratemporal facial nerve, 420
management
conservative management, 425
surgical management, 425–430
preoperative evaluation, 425, 426t
reanimation, children, 430
Facial plexiform neurofibromas, 333
Facial reconstruction
implants
bony skeleton, 80
calvarial reconstruction, 81, 81f
ear, 80–81
eyelid, 81
facial augmentation, 81
Facial rhytids, 483
Facial sensory deficits, 700
Facial skeletal augmentation. See also Osseous genioplasty
alloplastic materials, 546
complications, 548
mandibular augmentation
body/angle/ramus, 548, 548f–549f
chin, 548, 548f
midface augmentation
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infraorbital rim, 547, 547f
malar, 547
paranasal, 547
positioning and immobilization, 546, 546f
preoperative evaluation, 546
temporal augmentation, 547
Facial trauma
access incisions, 343, 344f
antibiotic prophylaxis, 343
craniofacial skeleton stability, 341
facial examination, 341–343, 342f–343f
radiographic evaluation, 343
regional blocks, 343, 344f
soft tissue injuries, 343–345
Fasciectomy, 861, 861f
Fasciocutaneous flaps, 26, 58, 823
Fasciotomy
compartment syndrome
compartments, 900, 902f
digital compartment release, 902, 903f
dorsal, 900, 902f
interossei and adductor compartments, 902, 903f
upper arm, 900, 901f
volar, 900, 902f
Fat
breast augmentation (BA), 559
grafting, 21
complications, 489
controversial issues, 489
facelifting, 515
indications, 488
lipofilling, 488
Poland syndrome, 620–621
processing, 489
surgical technique, 488–489
necrosis, 572
tissue engineering, 116–117
18-FDG positron emission tomography, 868
Felons, 673, 673f
Femoral nerve, 703
Fibroblast growth factor receptor (FGFR), 264
Fibroproliferative scars, 18
Fibrosis, 572
Fibrous dysplasia
clinical findings, 329
complications, 330
definition, 329
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etiology, 329–330
pathogenesis, 329–330
treatment, 330
Fibula free flap, 435
Fight bites, 674, 674f
Finger carpometacarpal joints, 804–805, 805f
Finger flexion, 755
tenodesis effect, 756
Finger metacarpophalangeal joints (MCPJ)
anatomy, 801, 801f
finger MCPJ dislocations
dorsal MCPJ dislocations, 802
volar MCPJ dislocations, 802
isolated finger MCPJ collateral ligament injuries, 802
sagittal band injuries, 801–802
Fingers
avulsion amputation, 848, 848f
distal interphalangeal joint injuries, 801
extensor apparatus, 763, 766f
pulley systems, 755, 756f
Fingertip defect
flap options, 681, 681t
microvascular toe pulp, 681
secondary intention, 680
V-Y advancement flap, 681
Firebreak skin grafts, 862
First dorsal metacarpal artery (FDMA) flap, 849, 850f
Fisher’s exact test, 150
Fitzpatrick skin type, 167
Flail arm, 702
Flap-based coverage, 823
Flap closure, 21
Flap reconstruction
anterolateral thigh perforator flap, 61
contemporary classification systems
fasciocutaneous flap, 58
muscle flap classification, 57, 58t
myocutaneous flap classification, 58
perforator flap classifications, 58
deep inferior epigastric flaps, 59–60
free-style flaps, 59
gluteal myocutaneous flap, 60
gracilis, 60–61
historical classifications, 57
lateral arm flap, 59
latissimus dorsi, 60
local tissue rearrangement
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keystone flap, 58
propeller flap, 58
patient selection, 57
pectoralis flap, 61
profunda artery perforator, 60–61
radial forearm flap, 59
rectus abdominis, 59–60
superficial inferior epigastric flaps, 59–60
superior gluteal artery perforator flaps, 60
supermicrosurgery, 59
thoracodorsal artery perforator flaps, 60
transverse/diagonal upper gracilis, 60–61
upper thigh flaps, 60–61
Flaps
application, 31–35
blood supply, 25, 26f
breast augmentation (BA), 559
classification, 26–31
content, 26–27, 26t, 27f
cutaneous, 26
defect assessing, 31–32
design, 31–35
distant flap, 679
distant pedicle, 684
fasciocutaneous, 26
free fasciocutaneous, 684
free flaps
abdomen-based flaps, 601–603, 603f–606f
gluteal artery perforator flaps, 604, 607f
medial thigh flaps, 603, 606f–607f
posterior thigh flaps, 604, 607f
gynecomastia, 577
keystone flap, 27, 30f
latissimus dorsi (LD) myocutaneous flap, 601, 601f–602f
local flap, 679
locoregional, 681
movement, 27, 28t
muscle, 26
myocutaneous, 26
nomenclature, 26–31
osteocutaneous, 26
osteomyocutaneous, 26
pedicle locoregional flaps, 679
physiology, 25
posterior interosseous artery (PIA) flaps, 685
principles, 25–35
propeller, 28, 30f
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proximity to defect, 27
regional flap, 679
reverse radial forearm, 28, 31f
rotation, 27, 29f
scars, 190–191
superficial circumflex iliac perforator (SCIP) flaps, 684
thumb reconstruction
cross-finger flap, 849–850
first dorsal metacarpal artery (FDMA) flap, 849
heterodigital neurovascular island pedicle flap, 850
local and regional flaps, 849
tissue expansion, 98
transposition, 27, 29f
venous insufficiency, 35
V-Y advancement, 27, 29f
Fleur-de-lis technique, 637, 637f
Flexor carpi radialis (FCR), 722
Flexor carpi ulnaris (FCU), 694, 698, 787
Flexor digitorum, 692
Flexor digitorum profundus (FDP) tendons, 702, 722
Flexor digitorum superficialis (FDS), 698
Flexor pollicis longus (FPL), 692, 702, 721
Flexor tendon injuries
treatment, 757
Zone 1, 756
Zone 2, 756
Zone 3, 756
Zone 4, 756
Zone 5, 756
Flexor tendon repair and reconstruction
anatomy, 755f
flexor digitorum profundus (FDP), 755
flexor pollicis longus (FPL), 755
pulley systems of fingers, 755, 756f
vascularity, 755, 756f
clinical evaluation, 756, 757f
complications, 759
management
core suturing, 757, 758f
epitendinous sutures, 758
factors, 757
Leddy classification of Zone 1 flexor tendon injuries, 758, 758f
quadriga effect, 758
repair strength without epitendinous suture, 757, 758t
tetanus prophylaxis, 757
Zone 1, 758
Zone 2, 759
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Zone 3, 759
Zone 4, 759
Zone 5, 759
rehabilitation and outcomes, 759, 759f
tendon reconstruction, 759–760
Flexor tenosynovitis
Bruner incisions, 674
characteristics, 673
symptoms, 673
Floor of mouth reconstruction
defect analysis, 444–445, 446f
flap choices, 445
Fluid balance, 137
Fluid monitoring, 137
Focal adhesion (FA), 10
Focal swelling, 672
Foley catheter, 646
Forced warm air blankets, 633
Forearm, 897f
brachioradialis, 666, 667f
distal radioulnar joint (DRUJ), 663
extensor wad, 666, 667f
FCR tendon, 666, 667f
palmaris longus tendon, 666, 667f
photography, 122, 123f
radius, 895
radius and ulna, 663, 663f
rigid interosseous membrane, 895
triangular fibrocartilage complex (TFCC), 663, 664f
ulna, 895
Forehead
botulinum toxin, 484
brow
aging, 494–496, 496f–497f
anatomy, 493–494
history, 493
nasal reconstruction, 401–404, 405f
Forehead and scalp
anatomy, 365
reconstruction, 365–367
Forehead tissue expansion, 99
Former smokers, 589
Forward-flow test, 41
Fractional photothermolysis, 219
Fractionated photothermolysis lasers, 467–468
Fracture classification, 976, 976f
Fracture nonunion, 736
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