Tarascon Plastic

& Reconstructive
Surgery Pocketbook
From the publishers of the Tarascon Pocket Pharmacopoeia®

James A. Chambers, MD, MPH

Lt Col, USAF, MC, SFS
Plastic / Hand Surgeon
San Antonio Military Health System
San Antonio, TX

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 World Headquarters
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 DEDICATION
To my wife Sylvia, my children Neil & Brette, and my parents and brother,
whose support has been unyielding.

To Dr. Louis Carter, whose service and example convinced me to pursue this
remarkable field.

To Dr. Luis Vásconez, enthusiastic pioneer, esteemed professor, consummate

gentleman, and friend.

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 Cover: Lithograph of plate from 15th century Italian surgeon Gasparo
Tagliacozzi (De Curtorum Chirurgra perinsitionem, Libri Duo Venice, 1597) who
wrote “We restore, repair, and make whole those parts which nature has given
but fortune has taken away not so much that they may delight the eye, but that
they may buoy up the spirit and help the mind of the afflicted.”

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 CONTENTS
Editorial Board vi 4 Breast 129
Anatomy 129
Note from the Author vii Reconstruction 129
Acronyms viii Reduction Mammaplasty 132
Augmentation 134
1 Wound Healing, Coverage,
and Locoregional 5 Torso and Pressure Ulcers 137
Anesthesia 1 Chest Wall Reconstruction 137
Phases of Wound Healing 1 Aesthetic 139
Wound Care and Coverage 6 Lower Extremity 141
Principles 4 Trauma 141
Regional and Local Management of Bony
Anesthesia 17 Injury in Leg 144
2 Head and Neck 21 7 Burns 145
Anatomy 21 Initial Care and Resuscitation 145
Surgical Approaches 33 Thermal Burns 147
Soft Tissue Reconstruction 35 Inhalation Injury 149
Trauma 44 Electrical Burns 150
Tumors 55 Chemical Burns 151
Congenital 61 Surgical Management
Aesthetics 79 of Burn Wounds 152
3 Hand and Peripheral Frostbite 156
Nerve 83 8 Skin: Dermal Malignancies,
Anatomy 83 Vascular Anomalies, Lasers,
Evaluation 94 Peels, and Injectables 157
Fractures and Dislocations 98 Malignancy 157
Infection and Injection 107 Vascular Anomalies 159
Inflammatory and Degenerative Vascular Malformations 161
Disorders 109 Lasers and Chemical Peels 163
Tumors 111 Injectable Fillers and Botox 164
Soft Tissue Reconstruction 119
Congenital 121
Other 128 Index 165

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 vi Editorial Board

EDITORIAL BOARD
Affiliations are given for information purposes only, and no affiliation sponsor-
ship is claimed. James A. Chambers, MD, MPH, authored this book in his private
capacity. The views expressed in this book do not necessarily represent the
views of either the United States Air Force or the United States Government.

David E. Ruchelsman, MD Franziska Huettner, MD

Orthopaedic Hand Surgeon Chief Resident, Plastic Surgery
Tufts University School of Medicine University of Alabama at Birmingham
Boston, MA Birmingham, AL

Jason J. Hall, MD Daniel Petrisor, DMD, MD

Plastic/Craniofacial Surgeon Oral and Maxillofacial Surgeon
UT Houston Medical School Oregon Health & Science University
Houston, TX Portland, OR

Rodney K. Chan, MD Rohit K. Khosla, MD

Plastic Surgeon Plastic/Craniofacial Surgeon
US Army ISR Burn Center Stanford University
Fort Sam Houston, TX Palo Alto, CA

Quintessa Miller, MD Simon G. Talbot, MD

Lt Col, USAF, MC Plastic/Hand Surgeon
Plastic Surgeon Harvard University/Brigham &
San Antonio Military Health System Women’s Hospital
San Antonio, TX Boston, MA

Ankit Desai, MD James N. Long, MD

Plastic Surgeon Plastic Surgeon
Desai Plastic Surgery University of Alabama at Birmingham
Jacksonville, FL Birmingham, AL

Ted Ferguson, MD Michael Davis, MD

Lt Col, USAF, MC Lt Col, USAF, MC
Consultant to Air Force Surgeon Regenerative Medicine Research
General, Plastic Surgery Chief
Wilford Hall Ambulatory Surgery US Army Institute for Surgical
Center Research
Lackland AFB, TX Fort Sam Houston, TX

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 Note from the Author vii

NOTE FROM THE AUTHOR

The Tarascon Plastic & Reconstructive Surgery Pocketbook is intended as a quick
reference for the practice of plastic and reconstructive surgery. It represents
a compilation of facts and techniques that I have found useful and are refer-
enced where thought to be particularly important. If you find an error or wish to
make a suggestion, please let us know (e-mail: editor@[Link]).
James A. Chambers

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 viii Acronyms

ACRONYMS
AbDM abductor digiti minimi
AIN anterior interosseous nerve
APL abductor pollicis longus
AVN avascular necrosis
BR brachioradialis
CMC carpometacarpal joint
CRPP closed reduction (and) percutaneous pinning
DIP distal interphalangeal
DIPJ distal interphalangeal joint
DISI dorsal intercalated segment instability
DRUJ distal radioulnar joint
EAC external auditory canal
ECRB extensor carpi radialis brevis
ECRL extensor carpi radialis longus
ECU extensor carpi ulnaris
EDC extensor digitorum communis
EDM extensor digitorum minimus
EDQ extensor digiti quinti
EIP extensor indicis proprius
EPB extensor pollicics brevis
EPL extensor pollicis longus
FCR flexor carpi radialis
FCU flexor carpi ulnaris
FDP flexor digitorum profundus
FDS flexor digitorum superficialis
FPB flexor pollicis brevis
FPL flexor pollicis longus
IF index finger
IO interosseous
IP interphalangeal
IPJ interphalangeal joint
LABCN lateral antebrachial cutaneous nerve
LF long (or little) finger (author recommends using MF for
middle finger and SF for small finger for disambiguation)
LT lunotriquetral
MACS minimal access cranial suspension
MCPJ metacarpophalangeal joint
MF middle finger
MMF maxilomandibular fixation
MP metacarpophalangeal
MPJ metacarpophalangeal joint
N nasion
NOE nasoorbital fracture

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 Acronyms ix
OP opponens pollicis
P1 shorthand for proximal phalanx (“P2” refers to middle
phalanx, and “P3” to distal phalanx)
Pg pogonion
PIA posterior interosseous artery
PIN posterior interosseous nerve
PIP proximal interphalangeal
PIPJ proximal interphalangeal joint
PL palmaris longus
PQ pronator quadratus
PT pronator teres
RASL reduction and association of the scaphoid and lunate
RF ring finger
ROM range of motion
RSN radial sensory nerve
S sella
SF small finger
SLAC scapholunate advanced collapse
SLIL scapholunate interosseous ligament
SMAS superficial musculoaponeurotic system
SNAC scaphoid nonunion advanced collapse
UCL ulnar collateral ligament
VBG vascularized bone graft
VISI volar intercalated segment instability
ZMC zygomaticomaxillary complex

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 1 ■ WOUND HEALING, COVERAGE,
AND LOCOREGIONAL ANESTHESIA

A. PHASES OF WOUND HEALING

1. Coagulation
a. Blood vessel injury → exposed subendothelial collagen → platelet
aggregation (platelet plug) + activation of coagulation pathway
b. Vasoconstriction followed by vasodilatation
c. Requires:
i. von Willebrand factor (vWF) for platelet ADHESION (binds on
glycoprotein Gp1b receptor)
ii. Fibrinogen for platelet AGGREGATION (forms connections
between platelets by binding GpIIb/IIIa receptors)
d. Activated/accelerated by thromboxane A 2, prostaglandin F2α (vaso-
constriction and platelet aggregation)
e. Inhibited by prostacyclin (vasodilatation and inhibits platelet
aggregation)
i. Medications
– Aspirin (irreversible cyclooxygenase inhibitor, decreases
thromboxane and prostacyclin synthesis)
– Clopidogrel (Plavix), cilostazol (Pletal) (competitive inhibi-
tors of platelet ADP receptor, GpII/III inhibitors, decrease
platelet AGGREGATION)
– Heparin (binds antithrombin III and increases its potency-
effecting factors II, V, VIII, IX, X, XI)
– Warfarin (inhibits vitamin K–dependent synthesis of fac-
tors II, VII, IX, and X, and proteins C and S)
ii. Diseases
– von Willebrand’s (decreased amount [Type I], decreased
function [Type II], or absence [Type III] of vWF; decreased
platelet adhesion)
– Hemophilia A (deficiency of factor VIII)
– Hemophilia B (deficiency of factor IX)
2. Infl ammation
a. Increased vascular permeability due to histamine and serotonin
b. Polymorphonuclear cell migration
c. Complement factor (5a), platelet aggregating factor, IL1, TNFα,
and others lead to NEUTROPHIL adherence
d. Clinical signs: rubor is redness, tumor is swelling, calor is heat,
dolor is pain

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 2 Wound Healing, Coverage, and Locoregional Anesthesia

e. Macrophages (release proteinases that degrade ECM [extracellular

matrix], remove foreign material)
f. Activated/accelerated by immunodeficiency
g. Inhibited by:
i. Medications
– Nonsteroidal anti-inflammatory medications (NSAIDs):
ASA, ibuprofen (Motrin), celecoxib (Celebrex), ketorolac
(Toradol), naproxen (Aleve) (block COX enzymes and reduce
prostaglandin production)
– Colchicine (inhibits phagocytosis of urate)
3. Proliferation
a. Formation of new tissue through:
i. Angiogenesis: increased expression of vascular cell surface adhe-
sion molecule (VCAM)-1, formation of new blood vessels
ii. Fibroplasia: fibroblasts produce collagen Type III, stimulated by
growth factors
iii. Epithelization: changes wound keratinocytes like migration,
proliferation, and differentiation
b. Activated by: cytokines
c. Inhibited by: Ehler-Danlos, Marfan syndromes
4. Contraction/remodeling
a. Contraction: centripetal movement of whole thickness of surround-
ing skin due to interaction of fibroblasts with extracellular materials
i. Fibroblasts become stimulated = myofibroblasts
b. Remodeling: increase in wound strength, collagen cross-linking,
Type I collagen replaces Type III collagen
i. Decrease in fibroblasts and capillary network
c. Activated by: MMPs (matrix metalloproteinases)
d. Inhibited by: Ehler-Danlos, Marfan syndromes
Summary of cell timeline in wound healing: i. Platelets
ii. Polymorphonuclear cells (PMN) iii. Macrophages iv. Fibroblasts
v. Lymphocytes
5. Substrates
a. Matrix
i. Collagen
– Produced by fibroblasts
– Crosslinking inhibited by d-penicillamine
– Vitamin C, oxygen, iron, α-ketogluterate required for
crosslinking
– Scurvy: vitamin C deficiency, inability of crosslinking
– Ehlers-Danlos syndrome: collagen disorder
– Marfan syndrome: fibrillin (collagen) defect
• Type 1: most common type, found in the bone, tendons,
and skin
• Type 2: cartilage

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 Wound Healing, Coverage, and Locoregional Anesthesia 3

• Type 3: primarily produced during wound healing

(replaced by type 1 after 3 weeks of wound healing)
• Type 4: basement membranes
• Type 5: cornea
ii. Glycosaminoglycans
iii. Elastin
b. Cytokines
i. Support wound healing
– TNF-α (source: macrophages)
– IL-1 (source: macrophages)
– IL-2 (source: T cells)
– IL-6 (source: macrophages, PMNs, fibroblasts)
– IL-8 (source: macrophages, fibroblasts)
ii. Inhibit wound healing
– IL-4 (source: T cells, basophils, mast cells)
– IL-10 (source: T cells, macrophages, keratinocytes)
iii. Other critical cytokines for wound healing
– PDGF (platelet-derived growth factor)
– VEGF (vascular endothelial growth factor)
6. Scars
a. Normal: mature over 12-month period; before that time, may be
mildly erythematous or raised
b. Hypertrophic: collagen grows within boundaries of the scar, usually
regresses somewhat after 12 months
c. Keloid: collagen grows beyond the scar, persists beyond 12 months
i. Tx: silicone sheeting, steroid injection, XRT, or excision com-
bined with any or all of these; significant rate of recurrence
7. Anatomy of the skin
a. Epidermis
i. Keratinized epithelium
ii. Avascular
b. Dermis
i. Vascularized
ii. Collagen and elastin fibers
iii. Strength of skin
iv. Form tension lines (Langer’s lines)
c. Papillary dermis
i. Meissner’s corpuscles (tactile corpuscles)
d. Reticular dermis
i. Hair follicles
ii. Sebaceous glands
e. Hypodermis (superficial fascia)
i. Sweat glands (thermoregulation)
ii. Loose connective tissue
iii. Fat
iv. Blood vessels, lymphatics, cutaneous nerves

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 4 Wound Healing, Coverage, and Locoregional Anesthesia

B. WOUND CARE AND COVERAGE PRINCIPLES

1. Wet → dry
a. Traditional means of dressing that gradually debrides by drawing
material into gauze interstices
b. Excessively moist wounds may require other dressings such as algi-
nates or Mesalt
2. VAC (negative pressure) dressing
a. Vacuum-assisted closure, negative-pressure wound therapy
b. Sponge dressing on wound creates forces, macro- and microstrain
i. Macrostrain: approximates wound edges, evenly distributes
negative pressure, removes exudate
ii. Microstrain: reduces edema, promotes perfusion and granulation
tissue formation by facilitating cell migration and proliferation
c. Worsens infection if grossly purulent, but may actually be bacterio-
static in minimally contaminated wounds
3. Surgical debridement of necrotic tissue to healthy tissue
4. Suturing
a. Enter skin with needle tip perpendicular to surface, and rotate
needle to follow the curve
b. Simple sutures most commonly performed, should slightly evert
edges for best healing and long-term appearance
c. Horizontal mattress suture excellent for everting stiff tissue such
as glabrous skin
d. Vertical mattress also useful for eversion, but highest risk of obvi-
ous suture tracks if not promptly removed
5. Grafts (transferred tissue w/o blood vessels)
a. Skin: split skin typically harvested at 0.0012"; does not include all
dermal elements; more reliable survival than full thickness, but
increased contraction
b. Fat: increasingly used to refine breast reconstruction and improve
slight contour irregularities, but overly large deposits prone to necrosis
c. Nerve: autologous nerve (i.e., sural, others) graft traditionally the
gold standard for spanning nerve gaps, but cryopreserved allograft
increasingly used
d. Bone: cortical bone valued for structural support whereas cancel-
lous bone provides stem cells and other resources to encourage
local bone growth
6. Flaps (transferred tissue with blood vessels, either intact or divided
to be anastomosed at recipient site) (see Tables 1.1, 1.2, 1.3 and 1.4)
a. Vascular supply
i. Random pattern: based on subdermal plexus w/o named blood
vessel
ii. Axial pattern: based on direct cutaneous vascular pedicles with
axial alignment of flap
– Flap area superimposed over territory of named artery
(McGregor IA, Morgan G, Br J Plast Surg, 1973;26(3):202–13)

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 Wound Healing, Coverage, and Locoregional Anesthesia 5

b. Method of transfer
i. Advancement: flap carried to new position by sliding technique,
w/o any rotation or lateral movement
– V-Y, Y-V
– Single pedicle
– Bipedicle

FIGURE 1.1 Advancement Flap.

Creation of Burow’s triangles at base facilitates movement of flap.

ii. Pivot: flap moved around pivot point

– Rotation (semicircular)

FIGURE 1.2 Rotation Flap.

Creation of triangle (alternate: back cut) at base facilitates movement.

FIGURE 1.3 V-Y Advancement Flap.

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 6 Wound Healing, Coverage, and Locoregional Anesthesia

– Transposition (rectangular)
– Z-plasty
• Variation of transposition flap; two triangular flaps are
reversed and rotated 90°
• Useful for lengthening scars or changing direction of scar
• Central limb is along scar, and the two other limbs must
be of equal length to central limb
• End result is with central limb perpendicular to original
orientation
• Angle of Z-plasty → theoretical gain in length of central
limb
○ 30° → 25%
○ 45° → 50%
○ 60° → 75% (most commonly performed)
○ 75° → 100%
○ 90° → 120%
• Optimal angle is 60° degrees (balances tension and gain
in length)
• One large Z-plasty releases more than multiple small
Z-plasties
x y

b B
a a b
B A

x2
y2
FIGURE 1.4 Z-Plasty.
Creation of 60° angles results in 75% increase in x-x’ to y-y’

– W-plasty
• Useful for scar lengthening or scar excision
• Cross mark lines are drawn across and perpendicular to scar
– Rhomboid flap

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 Wound Healing, Coverage, and Locoregional Anesthesia 7

A C
A B

FIGURE 1.5 Rhomboid Flap.

Geometry based on 60° and 120° angles, with limbs all equal length.
• Limberg variant
Closure of rhomboid defects with angle of 60°
○
Longitudinal axis of rhomboid excision parallels the
○
line of minimal skin tension
• Dufourmentel variant
○ Closure of rhomboid defects at any size and angle up to 90°
○ The short axis of the defect does not need to equal
each of its sides
– Interpolation/island
• Rotate on a pivot point into a defect that is near but not
adjacent to the donor side
• Flap must pass over or under intervening tissue
iii. Distant
– Pedicled (perfusing vessels included in the pedicle)
– Free (requires division of artery and vein with anastomosis
at recipient site)
c. Flap vasculature
i. Macrocirculation
– Musculocutaneous vascular system
• Segmental arteries
• Perforator arteries
• Musculocutaneous arteries perpendicular to skin
– Direct cutaneous arteries parallel to skin
– Cutaneous hierarchies/plexi
• Fascial
• Subcutaneous
• Cutaneous

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 8 Wound Healing, Coverage, and Locoregional Anesthesia

– Angiosomes (Taylor GI, Palmer JH, Br J Plast Surg, 1987;40(2):

113–41)
• Composite unit of skin and its underlying deep tissue
supplied by a source artery
• 40 named angiosomes linked by anastomotic arteries
– Low venous pressure zones (Vergote T, et al., Br J Plast Surg,
1993;46(2):168–72)
d. Flap types: by tissue involved
i. Cutaneous (arterial) and fasciocutaneous flaps
ii. Muscle and musculocutaneous flaps
– Improved tissue ingrowth into contaminated wounds com-
pared with fasciocutaneous flaps due to richer perfusion
TABLE 1.1 Classifi cation (Information from Cormack GC, Lamberty BG. Br J Plast
Surg. Jan 1984;37(1):80–7)

Type Description Examples

A Direct cutaneous pedicle (flap has Groin, reversed superficial sural

multiple small no named vessels)

B Septocutaneous pedicle (a large Radial forearm, scapular, posterior

solitary perforator) interosseous, lateral arm

C Musculocutaneous pedicle (multiple Paramedian forehead flap

segmental branches, necessitate
inclusion of source of vessel)

TABLE 1.2 Workhorse Regional Fasciocutaneous Flaps

Arc of Max. Size Source Sensory

Name of Flap Rotation POC (cm) Vessels Nerve

Groin Abdominal wall, Type 25 × 10 Superficial Lat cutanous

perineum A circumflex (T12)
iliac

Reversed Lower calf Type Variable Median Inconsistent

superficial A superficial
sural sural

Radial forearm Ant, post Type 10 × 40 Radial Lat + med

forearm, B antebrachial
elbow, upper cutaneous
arm, hand,
thumb

(continues)

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 Wound Healing, Coverage, and Locoregional Anesthesia 9
TABLE 1.2 (continued )
Arc of Max. Size Source Sensory
Name of Flap Rotation POC (cm) Vessels Nerve

Scapular / Shoulder, axilla, Type 20 × 7 Circumflex Lat,

Parascapular lateral B scapular postcutaneous
thoracic (transverse ICN 3–5
wall and
descending
branches)

Temporoparietal Ipsilateral face, Type 12 × 14 Superficial Auriculotemporal

fascia neck A temporal

Lateral arm Ant, post Type 15 × 8 Posterior radial Postbrachial

shoulder, B collateral cutaneous
elbow

Posterior Elbow, Type 18 × 8 Posterior m: post-

interosseous tecubital B interosseous interosseous
fossa, s: branch
prox volar dorsal
forearm antebrachial
cutaneous

Paramedian Nose, Type 8 × 6 Supratrochlear, m: frontal,

forehead infraraorbital C supraorbital zygomatic
area branch
facial nerve
s:
supratrochlear,
supraorbital

Postauricular Neck, parietal Type Postauricular,

scalp, lat A superficial
sup + middle temporal
third face

Deltopectoral Middle, lower Type 10 × 20 2nd, 3rd

third face, C perforating
intraoral branches
cavity, neck of internal
thoracic a.

(continues)

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 10 Wound Healing, Coverage, and Locoregional Anesthesia
TABLE 1.2 (continued )
Arc of Max. Size Source Sensory
Name of Flap Rotation POC (cm) Vessels Nerve

Groin Thorax, lower Type 15 × 30 Superficial Segmental

abdomen A inferior branches
epigastric a. T10–12

Superficial Lower abdomen, Type 15 × 7 Superficial Segmental

external groin, A external branches
pudendal perineum, pudendal T11–12
artery (SEPA), upper thigh
penile

Dorsalis pedis Lower third leg, Type 6 × 10 Dorsalis pedis, Superficial,

med + lat B first dorsal deep
malleolus metatarsal peroneal

TABLE 1.3 Classifi cation (Information from Mathes SJ, Nahai F, Plast Reconstr
Surg. 1981 Feb 67(2):177–87)

Type Description Examples

I One vascular pedicle Gastrocnemius, tensor fascia lata, anconeus,

vastus intermedius

II One dominant pedicle and Biceps femoris, rectus femoris, soleus,

one or more minor pedicles gracilis, temporalis, vastus lateralis,
(flap cannot survive on platysma, brachioradialis, abductor
minor pedicles alone) hallucis, abductor digiti minimi

III Two dominant pedicles Gluteus maximus, rectus abdominus,

serratus anterior, orbicularis oris,
semimembranosus

IV Segmental pedicles Extensor hallucis longus, sartorius, tibialis

anterior, vastus medialis, flexor digitorum
longus, external oblique

V One dominant pedicles and Latissimus dorsi, pectoralis major

several smaller segmental
pedicles (flap can survive
on segmental pedicles
alone)

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 TABLE 1.4 Flap Examples

Skin
Flap Paddle POC* Arc of Rotation Size (cm) Vessel (dominant/minor) Nerve (motor, sensory)

36364_CH01_001-[Link] 11
Gastrocnemius Possible I Inf thigh, knee, upper third tibia 20 × 8 Medial/lateral sural m: Tibial branches
(medial/ s: saphenous(m), sural(l)
lateral)

Tensor fascia Possible I Abdominal wall, groin, perineum, 5 × 15 Asc branch lateral circumflex m: superior gluteal
lata trochanter, ischium, sacrum femoral s: T12+ lat fem cutaneus

Soleus No II Middle (and distal) one third tibia 8 × 28 d: Popliteal, posterior tibial, m: posttibial + medial
peroneal, m: posterior tibial popliteal

Gracilis Possible II Groin, perineum, vagina, anus, 6 × 24 d: Asc branch med circumflex m: ant branch obturator
ischium femoral, m: superficial femoral s: ant fem cutaneus

Biceps femoris Possible II Ischium 15 × 45 d: perf. branches profunda femoris m: sciatic

m: profunda femoris, inf gluteal, s: postcutaneous (thigh)
sup lat genicular

Rectus femoris Possible II Anterior trunk, midabdomen, groin, 20 × 8 d:des branch lat circumflex femoral m: femoral
perineum m: lat circumflex fem, superficial s: ant fem cutaneous
femoral

Rectus Possible III Anterior thorax, groin, perineum, 25 × 6 d: sup + inf epigastric m+s: intercostal 7–12
Wound Healing, Coverage, and Locoregional Anesthesia

abdominus inferor trunk m: sub- and intercostal

11

(continues)

1/3/13 7:19 PM
 TABLE 1.4 (continued )
12

Skin
Flap Paddle POC* Arc of Rotation Size (cm) Vessel (dominant/minor) Nerve (motor, sensory)

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Gluteus maximus Possible III Sacrum, ischium + 24 × 24 d: sup + inf gluteal m: inf gluteal (L5–S2)
perineum, rectum, vagina m: branches profunda femoris, s: S 1–3, L 1–3
(gluteal thigh flap) lat circumflex femoral

Serratus anterior Possible III Chest wall, shoulder, axilla, back, 15 × 20 d: lateral thoracic, branches m: long thoracic (C5–7)
intrathoracic cavity thoracodorsal s: intercostal (T2–4)

Extensor hallucis No IV Lower third tibia 3 × 24 Branches ant tibial m: ant tibial
longus

Sartorius No IV Groin, knee 5 × 40 Branches superficial m: femoral

femoral

Tibialis anterior Possible IV Upper + middle third tibia 4 × 25 Branches anterior tibial m + s: ant tibial
Wound Healing, Coverage, and Locoregional Anesthesia

Latissimus dorsi Possible V Neck, skull, thorax, sternum, lower 25 × 35 d: thoracodorsal m: thoracodoral (C6–8)
fsce, upper abdomen m: branches postintercostal, s: lat cutaneous
lumbar

Pectoralis major Possible V Head, neck 15 × 23 d: pectoral branch m: lat/sup pectoral,

thoracoacromial med/inf pectoral
m: branches lat thoracic, IMA, s: intercostal 2–7
intercostal
* POC pattern of circulation

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 Wound Healing, Coverage, and Locoregional Anesthesia 13

iii. Prefabricated flaps

– Introduction of vascular pedicle to desired donor tissue,
which itself does not have its own axial blood supply. After
period of neovascularization (at least 8 weeks), this donor
tissue can then be transferred on newly acquired blood
supply (Guo L, Pribaz JJ, Plast Reconstr Surg, 2009;124(6
Suppl):e340–50)
iv. Prelaminated flaps
– Building a composite structure (e.g., adding cartilage to a
cutaneous flap) on reliable preexisting vascular bed; after
2–3 weeks, composite can be transferred to recipient bed
v. Reversed flap
– Refers to pedicled flap in which proximal arterial flow is
divided, and perfusion relies on retrograde arterial flow
from collaterals
7. Microsurgery
a. Anastomoses
i. Can be constructed as:
– End-to-end: technically easiest, but diminishes distal flow
(important in lower extremity with atherosclerosis poten-
tial, etc.)
– End-to-side: may be more technically difficult in some, but
better preserves distal flow
b. Planning
i. Consider angiogram to determine status of vessels, particu-
larly if trauma or concern for atherosclerosis
ii. Be cautious in planning multiple procedures at same time (stag-
ing may be preferable)
iii. Long operative time increases risk of thromboembolism and
infection
8. Flap physiology
a. Regulation of skin perfusion
i. Systemic
– Neural: sympathetic adrenergic fibers; alpha-adrenergic:
vasoconstriction; beta-adrenergic, cholinergic: vasodilatation
– Humoral: epinephrine, norepinephrine, serotonin, thrombox-
ane A 2, PGF2-α: vasoconstriction kinin, histamine, PG-E1:
vasodilatation
ii. Local (autoregulation)
– Metabolic: hypercapnea, hypoxia, acidosis, hyperkalemia:
vasodilatation
– Physical: myogenic reflex (due to distention of cutaneous
vessels), local hypothermia, increased blood viscosity:
vasoconstriction

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 14 Wound Healing, Coverage, and Locoregional Anesthesia

b. Hemodynamics of flap transfer

i. Chronologic (Krizek TJ, Hoopes JE, Symposium on Basic Science in
Plastic Surgery, Mosby, St. Louis, 1976 Vol 15, Ch 28, pp. 241–59)
– 0–24 h: decreased arterial blood supply; circulatory effi-
ciency decreased 0–6 hours, plateau 6–12 hours, increased
after 12 hours; congestion and edema
– 1–3 d: improved pulse amplitude, circulation stagnation 48
hrs, increasing longitudinal anastomosis and small vessels
– 3–7 d: increase circulatory efficiency until plateau day 7,
vascular anastomosis flap and wound bed function day 5–7,
increase vessel number and size
– 1 w: good circulatory function and blood flow between flap
and wound bed, pulsatile flow reestablished
– 1–2 w: no increase in vascularization, normal arterial pat-
tern and circulatory efficiency
– 3 w: vascular pattern equal to preoperative state, 90% of
final circulation, vascular connections flap and vascular bed
fully developed
– 4 w: diameter vessels decreasing, few remaining newly
formed vessels
c. Flap delay
i. Surgical interruption of portion of blood supply to flap before
transfer; typically done 7–14 days before anticipated definitive
procedure
*Note: This is different from division and inset of pedicled flaps, which
typically benefit from waiting 3 weeks after initial surgery.
ii. Goal: increase flap survival
iii. Theory: flap able to survive with fewer nutrients, increases
neovascularization, sympathectomy effects, vascular reor-
ganization, reactive hyperemia, acclimatization to hypoxia,
inflammation (Krizek TJ, Hoopes JE, Symposium on Basic
Science in Plastic Surgery, Mosby, St. Louis, 1976, Vol 15, Ch 28,
pp. 241–59)
iv. 0–24 hours: initial spasm up to 3 hours, the gradual dilatation
up to 24 hours
v. 24–72 hours: accelerated increase in diameter of flap arteries
at choke vessel level
vi. 72 hours to 7 d: gradual dilatation with vessel wall thickening,
reorganization of vessels parallel to axis of flap
vii. 7d and after: choke vessels remain permanently and irrevers-
ibly dilated (Dhar SC, Taylor GI, Plast Reconstr Surg, 1999;
104(7):2079–91)
d. Ischemia-induced reperfusion injury (IIRI): oxygen-derived free rad-
icals formed during anaerobic metabolism with reperfusion. After a
critical period of ischemia, no reflow phenomenon occurs wherein
restoration of inflow is met with failure to successfully restore per-
fusion and venous outflow.

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 Wound Healing, Coverage, and Locoregional Anesthesia 15

9. Optimizing fl ap survival
a. Physical factors
i. Keep edges moist, minimize desiccation
ii. Avoid (vasoconstrictive) hypothermia
iii. Preconditioning flaps (intentionally induced periods of isch-
emia, followed by reperfusion, may periodically clamp pedicled
flap before division)
iv. Hyperbaric oxygen
b. Pharmacologic
i. Pro-survival
– Anticoagulants
• Heparin
• Leeches (Hirudo medicinalis) → Hirudin, for venous
congestion
○ Caveat: Aeromonas hydrophila, prophylactic antibiot-
ics (fluroquinolone or TMP-SMX)
• Aspirin
– Thrombolytics
• Urokinase, streptokinase for venous thrombosis
– Vasodilator
• Calcium (Ca)-channel blockers
• Topical nitroglycerin paste (advise patient may cause
headaches)
• Amrinone
• PGI2 and analog iloprost
– Free radical scavengers (none often used clinically)
• Allopurinol → inhibits xanthine oxidase → decreases
free radicals
• Superoxide dismutase
• Deferoxamine
– Oxygen: consider supplemental oxygen for borderline flaps
to increase survival
– Controversial:
• Dextran: inhibits platelet aggregation, but risk of ana-
phylaxis, pulmonary edema
10. Perfusion issues
a. Venous insufficiency
i. Suggested as primary cause of necrosis in pedicled flap tissue
(Krizek TJ, Hoopes JE, Symposium on Basic Science in Plastic
Surgery, Mosby, St. Louis, 1976, Vol 15, Ch 28, pp. 241–59;
Angel MF, et al., Plast Reconstr Surg, 1990;85(5):789–93)
b. Arterial insufficiency
i. Suggested as primary cause of skin flap failure (Kerrigan CL,
Plast Reconstr Surg, 1983;72(6):766–77)
ii. Combination of ischemia, inflammation, sympathectomy; may
be the cause for flap failure

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 16 Wound Healing, Coverage, and Locoregional Anesthesia

iii. Can cause irreversible damage to flap if ischemia extends

4–8 hours
iv. Vascular system changes irreversible after 12 hours, no perfu-
sion possible, “no-reflow,” flap death
11. Monitoring fl ap viability
a. Physical exam
i. Color (pale suggests arterial insufficiency; blue, violaceous,
dusky, cyanotic coloring suggests venous insufficiency)
ii. Warmth (cool suggests arterial insufficiency)
iii. Turgor (flaccid suggests arterial insufficiency, turgid/stiff sug-
gests venous insufficiency)
iv. Bleeding (stab flap with 25-g needle, should get slow, bright
red bleeding; markedly delayed or no bleeding suggests
arterial insufficiency; rapid dark bleeding suggests venous
insufficiency)
*Note: Vascular insufficiency pattens can be mixed. For example, pro-
longed venous insufficiency leads to capillary hypertension which
ultimately diminishes arterial inflow as well.
b. Dye
i. Fluorescein: administer 15 mg/kg IV, then examine in darkened
room using Wood’s (UV) lamp after waiting at least 15 minutes.
Perfused tissues will appear chartreuse
– May underestimate potentially viable tissue
ii. Indocyanine green: can be given multiple times during case
to assess flap and skin viability. SPY® system provides 10 cc
saline to mix with powdered dye; inject 5 cc of solution IV, then
view perfusion under camera
c. Other
i. Implantable Doppler (Cook-Swartz Doppler probe)
ii. Transcutaneous oxygen tension measurement
12. Managing perfusion problems
a. Arterial
i. Ensure patient is adequately hydrated and good systemic BP,
not cold or in significant pain
ii. If pedicled flap, may need to de-rotate or set back in original
location in OR
iii. If free flap, may need to revise arterial anastomosis or perform
thrombectomy/thrombolysis in OR
b. Venous
i. Ensure operative area elevated as much as practicable
ii. Consider:
– Releasing insetting suture(s)
– Topical nitroglycerine (advise patient may experience headache)
– Leeches (prophylax against Aeromonas hydrophila with FQ
or TMP-SMX; inform patient blood transfusion(s) will almost
certainly be required)
– Return to OR for evaluation of anastomosis

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 Wound Healing, Coverage, and Locoregional Anesthesia 17

13. Skin expansion

a. Expanders are silicone elastomers connected to subcutaneous
valve
b. After injection, wait 2–3 weeks, then expand every 1–2 weeks until
at goal volume
c. Endpoints for expansion visits: pain or blanching skin
i. Surface area gained of expanded tissue in relation to shape of
the expander:
– Round base: 25% gain
– Rectangular base: 38% gain
– Crescent base: 32% gain (van Rappard, et al., Plast Reconstr
Surg, 1988;82(5):833–9)
ii. Base expander should be 2.5 times larger than the defect to be
closed
d. Rectangular expanders (aside from for breast) most commonly used
e. Histologic changes
i. Thickens epidermis, thins dermis and subcutaneous tissue
ii. Increases hydroxyproline and collagen
iii. Stimulates angiogenesis, increases perfusion
f. Complications: infection, erosion, migration/rotation

C. REGIONAL AND LOCAL ANESTHESIA

1. Regional
a. Head and neck
i. Infraorbital (branch of V2)
– Numbs lip, medial cheek, lateral nose, lower lid, and buccal
gingival to mesial ½ of first molar, as well as nearby teeth
– Exits 4–7 mm below inferior orbital rim beneath medial
limbus; can be approached intra-/extraorally
ii. Greater palatine
– Numbs palatal mucosa to ipsilateral first premolar w/ 1–2 mL
– Exits ½-way between teeth and midline palate at ~second
molar
iii. Nasopalatine
– Numbs palatal mucosa from canine to contralateral canine
w/ 0.5–1 mL
– Exits midline ~5–7 mm posterior to maxillary incisors
iv. Inferior alveolar
– Numbs ipsilateral mandibular dentition and buccal mucosa
anterior to second premolar w/ 2–3 mL
– Place needle at 45° angle, ~1 cm above occlusal plane, at
anterior-medial edge of ramus mucosa down to level of bone
v. Lingual
– Numbs entire ipsilateral lingual mucosa and hemitongue
w/ 1–2 mL
– Approach is same as for inferior alveolar n. (above), but
withdraw needle 5 mm

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 18 Wound Healing, Coverage, and Locoregional Anesthesia

vi. Buccal (branch of V3)

– Numbs buccal mucosa and gingiva anterior to first premolar
w/ 2–3 mL
– Place needle in retromolar mucosa over anterior surface of
ramus
vii. Mental (note: inferior alveolar nerve covers this block as well)
– Numbs buccal mucosa and gingival anterior to first premo-
lar w/ 2–3 mL
– Exits below second premolar; inject mucosa at base of
vestibule
b. Upper extremity
i. Brachial plexus
– Supraclavicular block
• Where brachial plexus passes between clavicle and first
rib, after passing through scalene muscles
• Ultrasound guided
– Infraclavicular block
• Numbs elbow, forearm, hand
• Insert needle at 45° angle and advance parallel to the
line connecting the medial clavicular head and coracoid
process
– Axillary block
• Numbs forearm and hand
• Arm abducted, externally rotated, and flexed at elbow
• Place finger on axillary artery as high in axilla as pos-
sible, insert needle at 30° angle toward the artery and
enter sheath, aspirate, then inject
ii. Wrist block
– Numbs median, ulnar, radial (superficial branch) areas for
surgery hand and fingers w/ 5 mL per nerve
• Median: inject between tendon flexor palmaris longus and
flexor carpi radialis under deep fascia
• Ulnar: insert needle under tendon of flexor carpi ulnaris
just above ulnar styloid process, as well as above tendon,
and inject
• Radial: field block, inject subcutaneously just above
radial styloid, aiming medially
iii. Digital block
– Numbs fingers w/ 2–3 mL per side
– Ring, volar, dorsal nerve block
• Volar: insert needle at palmar lateral aspect of base of
finger, direct toward base phalanx, 2 mL injected slowly
• Dorsal: insert needle at dorsolateral aspect of base of fin-
ger, direct anteriorly toward base phalanx, 2 mL injected
slowly while withdrawing the needle

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 Wound Healing, Coverage, and Locoregional Anesthesia 19

iv. Intravenous regional (Bier block) (Bier A, Archiv fur Klinische

Chirurgie 86: 1007–16)
– Complete anesthesia and motor paralysis after IV injection
of anesthetic into previously exsanguinated limb
– Exsanguinate hand/forearm, inflate tourniquet, then inject
30–50 mL of 5% lidocaine w/o epinephrine
• Provides useful anesthesia for up to 1 hour. Do not release
tourniquet after any less than 20 minutes to minimize risk
of lidocaine toxicity.
• Recommend using double-cuff tourniquet. Inflate proxi-
mal cuff first; if becomes uncomfortable with time, inflate
distal then deflate proximal
2. Local
a. Types
i. Amides
– Longer duration of action
– Degradation in liver
– Rare allergic reactions (think amide = amigo)
– Examples have two “i”’s in generic name
ii. Esters
– Shorter duration of action
– Degradation in plasma by acetylcholinesterase
– Allergic reaction more common due to PABA (para-amino-
benzoic acid) as byproduct of degradation
– Can cause methemoglobinemia
– Examples have one “i” in generic name
b. Signs of toxicity: perioral numbness, metallic taste, blurred vision,
tinnitus, hallucinations, slurred speech, twitching, seizures, cardio-
vascular collapse
i. Treatment: maintain airway (intubate if necessary), benzodiaz-
epines for seizures
c. Maximum dose
i. For infiltrative injection
– Lidocaine
• W/o epinephrine: 4.5 mg/kg
• W/ epinephrine: 7.0 mg/kg
– Bupivacaine
• W/o epinephrine: 2.0 mg/kg
• W/ epinephrine: 3.0 mg/kg
ii. For tumescent infiltration (used in liposuction)
– Lidocaine: up to 45 mg/kg

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36364_CH01_001-[Link] 20 1/3/13 7:19 PM
 2 ■ HEAD AND NECK

A. ANATOMY
1. Osteology
a. Vault
i. Frontal bone
ii. Temporal bone
iii. Parietal bone
iv. Occipital bone
b. Face
i. Zygoma
– Articulates w/ greater wing of sphenoid, maxilla, frontal,
and temporal bones (last joints via slender zygomatic
arch) forming two faces, the lateral (malar) and the medial
(orbital). Arch is formed by junction of zygoma and zygo-
matic process of temporal bone
– Attachment for masseter (major deforming force w/ frac-
ture), temporalis, zygomaticus, portion of orbicularis oculi
• Ethmoid
• Sphenoid
• Maxilla
• Palatine
c. Sinuses
i. Frontal: absent at birth, begin to form by 2 yrs, radiographically
visible by 6 yrs, full size by 15 yrs
– Pyramid-shaped w/ apex superior and inferior floor that
forms medial aspect of orbital roof
– Posterior table forms portion of anterior cranial fossa, rela-
tively thin, 0.1 to 4.8 mm
– Anterior table forms portion of forehead, brow, glabella, av.
4 mm thick, up to 12 mm
– 10% of patients with unilateral sinus, 5% minimal sinus,
4% no sinus
– Nasofrontal recess (NFR) provides drainage for each frontal
sinus (FS), with ostial dimensions of 3 × 4 mm located at
posterior inferior aspect of sinus floor
ii. Maxillary
iii. Ethmoidal
iv. Sphenoid

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 22 Head and Neck

d. Mandible
i. Coronoid process: temporalis muscle inserts here
ii. Condylar process: articulates with glenoid fossa
iii. Angle: masseter (lateral) and medial pterygoid (medial) muscles
attach here
iv. Alveolar process: supports teeth
v. Cartilaginous disk: at temporomandibular joint (TMJ), serves
as point of attachment of transverse head of lateral pterygoid
muscles
e. Fissures and foramina
i. Skull base
– Foramen ovale
• Contains V3
– Stylomastoid foramen
• Contains CN VII
– Jugular foramen
• Contains CN IX, X, and XI
– Foramen spinosum
• Contains middle meningeal artery
ii. Intraorbital
– Optic canal
• Passes through lesser wing of sphenoid
• Contains optic nerve (CN II) and ophthalmic artery and vein
– Superior orbital fissure
• Bounded by the greater and lesser wings of the sphenoid
and ethmoid
• Contains CN III, IV, VI, and sympathetics
– Inferior orbital fissure
• Bounded by maxilla, zygoma, greater wing of the sphenoid
• Contains CN V2
iii. Facial
– Supratrochlear
– Infraorbital
– Maxillofacial
– Mental
– Anterior ethmoid foramen
• Contains anterior ethmoid vessels
2. Spaces
a. Buccal space
i. Above mylohyoid muscle
ii. Infection may result from spread from maxillary molars
b. Retropharyngeal space
i. Posterior to pharynx and extending down to level of T2
ii. Pathway of spread of dental infection into the mediastinum

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 Head and Neck 23

c. Submandibular space
i. Inferolateral to mylohyoid, superior to hyoid bone
ii. Contains submandibular gland, facial a., facial n vein, LN’s,
and inferior loop of CN XII
iii. Communicates anteriorly with submental space and posteriorly
with pharyngeal space
iv. Infection may result from spread from second and third man-
dibular molars (roots are beneath mylohyoid)
d. Submental
i. Medial to anterior bellies of the digastric muscles
ii. Contains submental lymph nodes
e. Sublingual
i. Superomedial to mylohyoid muscle
ii. Infection may result from spread from mandibular teeth ante-
rior to second molars
3. Vasculature
a. Common carotid
i. Branches off of aortic arch (left = direct branch, right = from
innominate artery)
ii. Bifurcates at the level of C4 into internal and external carotid
arteries
iii. External carotid branches (inferior → superior)
– Superior thyroid
– Ascending pharyngeal (branches posteriorly)
– Lingual
– Occipital (branches posteriorly)
– Facial
– Posterior auricular (branches posteriorly)
– Bifurcates terminally into the internal maxillary artery and
the superficial temporal artery
• Internal maxillary artery
○ Passes through pterygomaxillary fissure (at right angle
to inferior orbital fissure)
○ Common source of bleeding in facial fx
• Descending palatine is a branch along posterior aspect of
lateral nasal wall (at risk during LeFort 1 osteotomy)

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 24 Head and Neck

4. Innervation: cranial nerves (see Table 2.1)

TABLE 2.1 Cranial Nerves

Cranial Nerve Penetrates/Exits Function/Miscellaneous

I: olfactory Cribriform plate Sense of smell

II: optic Optic foramen Vision

III: oculomotor Superior orbital fissure Motor to rectus musculature

(inferior, superior, medial);
sphincter pupillae, ciliary
muscle

IV: trochlear Superior orbital fissure Motor to superior oblique

muscle

V: trigeminal
V1 – ophthalmic division V1 – superior orbital V1 – sensation to scalp,
V2 – maxillary division fissure upper eyelid, cornea, nose,
V3 – mandibular division V2 – foramen rotundum and meninges
V3 – foramen ovale V2 – sensation to lower lid
and cheek, nares, upper
lip, and palate
V3 – general sensation
anterior 2 ⁄3 tongue
– muscles of mastication

VI: abducens Superior orbital fissure Motor to lateral rectus

muscle

VII: facial (6 branches) Internal acoustic - From 2nd branchial arch

- temporal meatus and - Muscles of facial
- zygomatic stylomastoid foramen expression; no muscles
- buccal of mastication except
- mandibular (inn. posterior belly of
lower lip depressor digastric
muscles) - Enters innervated
- cervical muscles posteriorly
- auricular (separates except buccinator,
before facial n. trunk mentalis, levator anguli
enters parotid gland). oris
- Taste anterior 2 ⁄3 tongue

VIII: auditory Internal acoustic Hearing, balance

meatus
(continues)

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 Head and Neck 25
TABLE 2.1 (continued )

Cranial Nerve Penetrates/Exits Function/Miscellaneous

IX: glossopharyngeal Jugular foramen - general sensation and

taste post 2 ⁄3 tongue
X: vagus Jugular foramen Multiple functions.
Motor to levator veli
palatini, palatoglossus,
palatopharyngeus
XI: spinal accessory Jugular foramen Innervates SCM and
Emerges from upper trapezius
½ of posterior SCM
before passing
between investing and
prevertebral fascia to
supply trapezius
XII: hypoglossal Hypoglossal canal Motor to tongue

5. Innervation: peripheral nerves (see Table 2.2)

TABLE 2.2 Head & Neck Peripheral Nerves

Peripheral Nerve Penetrates/Exits Function/Miscellaneous

Infraorbital (maxillary n.; Foramen rotundum Sensation to cheek, upper

branch of V2) lip, lower eyelid, nose
Inferior alveolar (branch Mental foramen Sensation to mandibular
of V3) dentation and lower lip
and chin
Greater auricular Sensation to majority of ear
Lingual (branch of V3) Submucosal course Sensation to anterior 2 ⁄3
along lingual wall of of tongue
3rd molar *Frequent neuropraxia w/
oral instrumentation
Mental (branch of inferior Mental foramen (below Sensation to lower lip
alveolar n.) 1st / 2nd premolar) and chin
Recurrent laryngeal Motor innervation to larynx
(branch of CN X) and vocal cords
Superior laryngeal (branch Sensation to supraglottis
of CN X)

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 26 Head and Neck

6. Musculature (see Table 2.3)

TABLE 2.3 Muscles of Head & Neck

Muscle Origin : Insertion Function Innervation

MUSCLES OF MASTICATION
Temporalis Temporal fossa : coronoid Elevates mandible CN V3
process (last 5%)
Pterygoid, medial Lat. pterygoid plate, Elevates mandible CN V3
palatine bone, maxillary
tuberosity : medial
mandibular angle
Pterygoid, lateral Sphenoid and lat. Protrudes mandible CN V3
pterygoid plate : TMJ /
joint capsule
Masseter : lateral mandibular angle Elevates mandible Anterior division
of CN V3
Geniohyoid Inf. mental spine : ant. Depress mandible C1
hyoid
Genioglossus mandibular mental spine : Depress mandible CN XII
hyoid, dorsum of tongue
Mylohyoid hyoid : body of mandible Depress mandible CN V3
Digastric muscles Anterior and posterior Depress mandible Ant: CN V3,
bellies differ Post: CN VII
MUSCLES OF FACIAL EXPRESSION
Frontalis No bony attachments. Raises brow CN VII
Blends with procerus,
corrugators, orbicularis
oculi, and galea
Buccinator No bony attachments Tightens cheeks, CN III
helps close mouth
Corrugator No bony attachments Raises eyebrows, CN VII
wrinkle forearm
Levator alae No bony attachments Raises lip edges CN VII
alaequae, labialis
superioris
Platysma No bony attachments Tightens anterior neck CN VII
Orbicularis oculi No bony attachments Closes eyelids CN VII
(continues)

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 Head and Neck 27
TABLE 2.3 (continued )

Muscle Origin : Insertion Function Innervation

MUSCLES OF FACIAL EXPRESSION
Levator palpebrae CN III
superioris
Orbicularis oris No bony attachments Purses/puckers lips CN VII
Risorius No bony attachments Retracts angle of CN VII
mouth
MUSCLES OF OROPHARYNX
Tensor veli Palatine aponeurosis and Tenses soft palate CN V3
palatini eustachian tube : spine (primary function in
of sphenoid and medial swallowing), opens
pterygoid plate (passes eustachian tube
inferiorly around
hamulus)
Levator veli Eustachian tube and Elevates velum CN IX, X
palatini petrous temporal (pharyngeal
bone : medial velar plexus)
aponeurosis
Palatoglossus Palatine aponeurosis : Lifts posterior CN X
tongue tongue to velum (controversial)
Palatopharyngeus Lateral pharynx : hard Tenses, depresses, CN IX, X
palate and displaces (pharyngeal
backwards the plexus)
velum. Constricts
pharynx (closes
nasopharynx from
oropharynx)
Superior Posterior buccinator and Pulls lateral/ CN IX, X
pharyngeal tongue : occipital bone posterior (pharyngeal
constrictor pharyngeal walls plexus)
medially to narrow
pharynx
Musculus uvulae Shortens uvula CN IX, X
(pharyngeal
plexus)

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 28 Head and Neck

7. Lymphatics and salivary glands

a. Lymph node levels (used for neck dissection)
i. Ia—submental
ii. Ib—submandibular
iii. II—upper jugular: medial to SCM, superior to hyoid bone/carotid
bifurcation
iv. III—middle jugular: inferior to hyoid/carotid bifurcation, supe-
rior to cricoid/omohyoid
v. IV—lower jugular: inferior to omohyoid, superior to clavicle
vi. V—posterior triangle
vii. VI—anterior compartment (paratracheal, pretracheal nodes)
b. Salivary glands
i. Parotid
– Lies anterior to ear, deep to the muscular layer of the face
Main trunk of CN VII divides it into superficial and deep lobes
– Stensen’s duct
• Runs in the same anatomic plane as facial vessels and
CN VII branches
• Travels along line between ear canal and oral commissure
and enters oral cavity opposite maxillary second molar
– Submandibular
– Sublingual
8. Eye
a. Anatomy
i. Orbit: seven bones comprising four walls (frontal, maxilla, zygo-
matic, ethmoid, lacrimal, greater and lesser sphenoid wings,
palatine)
ii. Bones
– Frontal: roof, part of lateral wall; superior oblique muscle
originates on trochea of frontal bone
– Maxilla: floor; anterior portion of lacrimal groove; medial
canthal ligament attaches to frontal process of maxilla;
inferior oblique muscle originates on maxilla
– Zygoma: part of floor, majority of lateral wall; lateral canthal
ligament attaches to frontal process of zygoma at Whitnall’s
tubercle 5–10 mm from lateral rim
– Ethmoid: majority of medial wall
– Lacrimal: part of medial wall; posterior portion of lacrimal
groove
– Sphenoid
• Greater wing: adjacent to superior and inferior orbital
fissures
• Lesser wing: contains optic canal
– Palatine

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iii. Walls
– Superior (roof): arched, thin, but rarely fractured due to pro-
tection of frontal sinus, frontal bone, and supraorbital rim;
exception is children. See orbital fx section below that follows
– Inferior (floor): medial aspect is maxillary bone
– Medial: composed of palatine bone, lacrimal bone, and
lamina papyracea of the ethmoid
– Lateral: composed of zygoma and greater wing of sphenoid
iv. Eyelid: upper lid has four layers; lower lid similar, but lacks
levator muscle
– Skin and subcutaneous fat: loose, can accommodate sig-
nificant fluid/edema
– Musculature (orbicularis oculi)
• Divisions
○ Orbital (outer rim; provides tight eyelid closure)
• Originates from medial orbital rim and medial canthal
tendon
○ Palpebral (exceedingly thin; provides reflex/uncon-
scious closure, and aids lower lid contact w/ globe)
• Preseptal: between orbital and pretarsal; superficial to
orbital septum
○ Originates from medial canthal tendon and lacrimal
diaphragm, inserts in lateral canthal tendon
• Pretarsal: innermost; superficial to tarsal plate
○ From medial canthal tendon and contribute to lateral
canthal tendon
• Vasculature: from external facial a. branches that arise
from branches of ophthalmic a
– Tarsus
• Upper tarsal plate ~10 mm in vertical height (~29 mm
long and 1 mm thick)
• Lower tarsal plate ~4 mm in vertical height (~29 mm
long and 1 mm thick)
– Conjunctiva: palpebral and bulbar components
– Orbital septum: extends from arcus marginalis (bony rim
of orbit) toward tarsus. In upper lid, inserts into levator
aponeurosis 2–5 mm above tarsus. In lower lid, it attaches
to tarsus and fuses with periorbita at bony rim. Medially,
attaches to lower end of anterior lacrimal crest, passing
from lower to upper lid under orbicularis oculi. Laterally,
passes just anterior to lateral canthal tendon
– Medial canthus: fibrous support of the lid; extends from medial
tarsus and has anterior and posterior limbs that surround the
lacrimal sac. Main insertion is posterior lacrimal crest
– Lateral canthus: fibrous support of the lid; extends from the
lateral tarsal margin and inserts onto Whitnall’s tubercle
~1.5 mm posterior to lateral orbital rim

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b. Physiology
i. Lacrimal system
– Tears produced by three sets of glands
• Goblet cells (mucinous product)
• Accessory lacrimal glands (aqueous product)
• Meibomian, Zeiss, Moll (oily product)
– Dry eyes
• Etiology: computer use, antihistamines, antihyperten-
sives, antidepressants, diabetes, lupus, thyroid disease,
rheumatoid arthritis, Sjögren’s syndrome
• Evaluate with Schirmer’s test
○ Schirmer’s I: filter paper strip inserted into lower con-
junctival sac and allowed to sit for 5 minutes. (a normal
test has >10 mm of wetting of the filter paper)
○ Schirmer’s II: similar to Schirmer’s I, but topical anes-
thetic is used, eliminating reflex tearing
– Epiphora: excessive tearing; investigate lacrimal system for
obstruction
– Chemosis: edema of the conjunctiva; nonspecific sign of eye
inflammation
ii. Scleral show: seen in 5% of population
iii. Eye opening (lid retraction)
– Upper lid (90% of eye opening)
• Levator palpebrae superioris: innervated by CN III (oculo-
motor nerve)
• Müller’s muscle: innervated by sympathetic fibers, loss of
which (Horner’s syndrome) results in 2–3 mm of ptosis
– Lower lid
• Capsulopalpebral head of inferior rectus muscle
iv. Pupillary function
– Miosis (small pupil) = parasympathetic; mydriasis (dilated
pupil) = sympathetic
– Direct papillary response: pupil should constrict in response
to direct (ipsilateral) light (intact ipsilateral afferent optic
nerve = CN II; efferent parasympathetics = CN III)
– Consensual papillary response: pupil should constrict in
response to contralateral light (intact contralateral = CN II;
ipsilateral = CN III)
– Accommodation: pupils should constrict when focused on
approaching object (intact = CN II, III)
– Afferent papillary defect (Marcus-Gunn pupil): decreased or
absent pupillary constriction of both eyes when light shined
in affected eye
– Horner’s syndrome: miosis, lid ptosis, anhydrosis (due to
sympathetic chain interruption in upper thorax)

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9. Nose
a. Support
i. Proximal third: nasal bones, bony septum
ii. Middle third: upper lateral cartilages, cartilaginous septum
iii. Distal third: cartilaginous septum, lower lateral cartilages
(medial, middle, and lateral crura)
b. Soft tissue envelope
c. Vasculature
i. Angular arteries (from facial aa): supply each side of nose
ii. Lateral nasal and septal arteries (from facial artery): provide
branches to ala and septum
iii. Dorsal nasal branch (of ophthalmic aa): supply dorsum, nasal
sidewalls
iv. Infraorbital branch (of internal maxillary aa): supply dorsum,
nasal sidewalls similar to to dorsal nasal branch of ophthalmic
artery
d. Innervation
i. Sensory (from trigeminal nerve = CN V)
– Ophthalmic division (V1)
• Nasociliary n.: direct sensation to nose
• Infratrochlear n.: indirect sensation to nose
• External branch of anterior ethmoidal n.
– Maxillary division (V2)
• Provides branches via infraorbital nerve to nasal side-
walls and caudal septum
ii. Motor: facial nerve (CN VII) innervates procerus, depressor
septi nasi, and nasalis
10. Ear
a. External structure: helix (w/ root and tail), antihelix (w/ superior and
inferior crura), tragus, antitragus, intertragal, concha, scapha, cymba,
lobule. Normal dimensions: 6–6.5 cm high, 3.5 cm wide, projects
17–21 mm from temporal scalp
b. Vasculature
i. Superficial temporal artery (from ext carotid): supplies lateral
auricle
ii. Posterior auricular artery (from ext carotid): supplies posterior
auricle, lobule, and retroauricular skin
iii. Occipital artery (from ext carotid): supplies posterior auricle, lob-
ule, and retroauricular skin similar to posterior auricular artery
c. Innervation
i. Great auricular nerve (C2, C3): sensory to lower half of lateral
ear and posterior auricle
ii. Auriculotemporal nerve (V3): sensory to superolateral surface
of ear and anterior and superior external auditory canal
iii. Lesser occipital nerve: sensory to superior cranial surface of ear
iv. Arnold’s nerve (auricular branch of vagus): sensory to concha
and posterior external auditory canal

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11. Scalp
a. Layers: Skin, Connective tissue (subcutaneous tissue), Aponeurosis
(frontalis muscle, galea), Loose areolar layer, Periosteum
b. Most mobility in skin/subcutaneous tissue over parietal scalp; little
mobility on vertex or occiput
12. Oral cavity and teeth
a. 32 adult teeth (16 in each dental arch): 12 molars, 8 bicuspids,
4 canines, 4 lateral incisors, 4 central incisors
i. Numbered from right to left in maxilla (1–16) and left to right in
the mandible (17–32)
b. 20 primary teeth (10 in each dental arch): 4 molars, 2 canines,
2 lateral incisors, 2 central incisors
i. Lettered right to left in the maxilla (A–J) and left to right in the
mandible (K–T)
ii. There are NO bicuspid teeth in primary dentition
c. Dental terminology
i. Mesial: side of the tooth that is toward the center of the mouth
ii. Distal: side of tooth furthest from the center of the mouth
(toward the back of the mouth)
iii. Lingual: toward the tongue
iv. Buccal: toward the cheek
d. Alveolar ridge: bony ridge of both mandible and maxilla that contain
the tooth sockets (alveoli)
e. Palatal anatomy
i. Primary palate: derived from the premaxilla, portion of the bony
palate anterior to incisive foramen (just behind the central
incisors)
ii. Secondary palate: formed by the palatine process of the maxilla
and the palatine bone, posterior to the incisive foramen
13. Lips
a. Topography
i. Vermillion: red portion of lip, divided into dry (keratinized) and
wet or moist (nonkeratinized)
ii. Vermillion border (mucocutaneous line, white roll): transition
from skin to mucosa of lip
iii. Cupid’s bow: upper central vermillion border at base of philtral
columns (others define as entire upper lip)
iv. Intercommissural distance: in a normal adult at rest, 6 cm
b. Aesthetic units
i. Lateral wings: between philtral columns and nasolabial folds
ii. Philtrum: between philtral columns
iii. Lower lip: between vermillion and labiomental fold
iv. Vermillion: between vermillion border and dry-wet line

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c. Musculature
i. Orbicularis oris: divided into superficial and deep portions
ii. Superficial orbicularis: controls oral sphincter function, which
pouts/purses lips (acts as a coronal sphincter)
iii. Deep orbicularis: keeps lips coated to the teeth (acts as an
axial sphincter)
d. Innervation
i. Motor
– Facial n. (CN VII)
• Buccal branch
• Marginal mandibular branch
ii. Sensory
– Upper lip: infraorbital nerve (V2)
– Lower lip: mental nerve (V3)
e. Vasculature: facial artery gives rise to superior and inferior labial
arteries deep to orbicularis oris, 1 mm posterior to white roll, and
1 mm deep to lip mucosa
f. Lymphatics: upper and lower lateral lips drain to submandibular
nodes; central lower lip drains to submental nodes

B. SURGICAL APPROACHES
1. Periorbital (exposes infraorbital rim and orbit – medial and lateral
walls as well as floor)
a. Transcutaneous (subciliary, subtarsal, and infraorbital rim incisions)
i. Exposes infraorbital rim, orbital floor, medial and lateral orbital
walls, and superior maxilla
ii. Keep incision in thin eyelid skin (not malar) and avoid crossing
skin tension lines laterally if possible
iii. Mark skin incision 2 mm/7mm inferior to lashes (subciliary/
subtarsal)
iv. Subciliary incision has high incidence of lower lid malposition
when used for trauma exposure compared to subtarsal approach
b. Transconjunctival
i. Exposes orbital floor, will need transcaruncular extension or
lateral canthotomy for visualization of medial or lateral walls,
limited exposure of infraorbital rim
ii. Incise ~5 mm from depth of conjunctival fornix, can dissect
anterior or posterior to orbital septum for exposure of floor or to
access lower lid fat compartments
c. Supraorbital eyebrow
i. Exposes lateral wall and zygomaticofrontal (ZF) suture
ii. Incision placed in lateral tail of brow extending along lateral
orbital rim
iii. Scar is not in a natural crease and has a tendency to cause
brow alopecia

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d. Upper eyelid
i. Exposes upper medial orbital wall, superior orbital rim, orbital
roof, and ZF suture
ii. Incision placed in natural upper eyelid crease and can be
extended laterally in an existing skin crease for ZF suture
exposure
iii. Keep >1 cm between upper and lower lid incision extensions
laterally to avoid prolonged postoperative lid edema
2. Coronal (exposes frontal bones, upper face, zygomatic arch)
a. Zigzag incision beginning 1 cm superior and posterior to helical
root, extending posteriorly first
b. Incise behind hairline (in balding men, consider from preauricular
to preauricular or further back [mid-portion may curve anteriorly];
if possible, maintain ~4 cm behind hairline). A hemicoronal incision
may also be used but offers limited exposure
i. A preauricular extension can be used to access the TMJ or zygo-
matic arch
c. Keep hair out of field by twisting small bundles with hemostats and
placing rubber bands loaded on hemostat
d. Hemostasis may be aided by: injecting epinephrine solution into
subgaleal plane; running locking sutures of 2–0 monofilament along
edge; cautery knife; Raney clips
e. Mark midline, then lateral. Incise to areolar tissue below galea,
but above pericranium. Limit initial incisions between temporalis
muscles laterally to avoid excess bleeding
3. Transoral
a. Maxilla
i. Upper gingivobuccal sulcus incision
– Incision made ~5–7 mm on mucosa of upper lip, running
from first molar to contralateral first molar
– Leave a small cuff of muscle on mucosa to aid in closure
– Can expose maxilla, anterior zygoma, and access pterygo-
maxillary junction
b. Mandible
i. Lower gingivobuccal sulcus incisions
– Can tailor incisions to needed exposure; be mindful of the
mental nerve (foramen at level of second bicuspid)
– Similar principles as with upper incision
– Re-suspend mentalis with sutures or external taping to pre-
vent postoperative chin ptosis
4. Transfacial mandible
a. Submandibular (Risdon)
i. Incision placed ~2 cm below inferior border of mandible
ii. Careful dissection through platysma (marginal mandibular
branch of CN 7 just deep to it)
iii. May require division of facial artery and vein for exposure

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b. Retromandibular: exposes superiorly to coronoid notch and inferiorly

to angle of mandible
i. Safest and most versatile for ORIF of angle, ramus, or sub-
condylar fx (adding transfacial trocar aids in accessing higher
level fx)
5. TMJ: preauricular incision (rhytidectomy incision)
a. Dissect posterior to parotid, staying above level of the tragal pointer
(facial nerve trunk)
b. Exposure of the posterior zygomatic arch will lead to the joint itself
6. Nasal
a. Open: offers best exposure of nasal anatomy, best incision for nov-
ice rhinoplasty surgeons
– Stairstep or inverted “V” incision at narrowest point of colu-
mella. These extend up the columella to marginal incisions
inferior to the lower lateral cartilages and allow for nasal
degloving
b. Closed (endonasal): allows for more limited dissection and less
postoperative edema than open approach. Surgery is done by feel
(“blind”), and is difficult to teach and learn. Difficult to access
lower lateral cartilages. Incision choices:
i. Intercartilaginous: between upper and lower lateral cartilages
ii. Transcartilaginous: through lower lateral cartilage
iii. Infracartilaginous (marginal): caudal to the lower lateral
cartilages
iv. Transfixion incision: separates membranous septum from cau-
dal cartilaginous septum, allows for exposure of septal carti-
lage and frees nasal tip from the septum

C. SOFT TISSUE RECONSTRUCTION

1. Facial wounds
a. General
i. Ensure appropriate attention to tetanus status
ii. Assess integrity of facial n., parotid duct, lacrimal apparatus,
and external auditory meatus
iii. If immediate repair not pursued, keep open wound moist with
saline dressings or petrolatum gauze dressing
iv. Thoroughly débride and irrigate all wounds before closure
(includes scrubbing out “road rash,” particulate matter, etc.)
b. Lacerations
i. Layered, primary closure with meticulous hemostasis is needed
to avoid dead space and hematoma
ii. Drain large wounds as indicated
iii. Deep tissue is approximated with resorbable 3–0 or 4–0
undyed suture (Vicryl®, Monocryl®, etc.)

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iv. Epidermis is approximated with permanent 5–0 or 6–0 mono-

filament (consider fast-absorbing gut for children)
– Sutures removed from skin in ~5 days to avoid “railroad
track” scarring from suture tract epithelialization. Buttress
repair with Steri-Strips after suture removal as needed
v. Specific sites
– Scalp
• Ideally, approximate galea (water-tight), then epidermis
(staples or monofilament), although for expediency, single-
layer closure incorporating both layers can be utilized
• Primary closure of wounds <1 cm wide is facilitated by
undermining between galea and pericranium; wounds
wider than 1 cm generally require more complex closures
such as Z-plasty (laceration as central arm)
– Eyebrow: débride only obviously necrotic tissue, then close
in layers beginning at hairline
– Eyelid: evaluate possible injury to septum and levator
• Close lid in layers. Use nonabsorbable suture in tarsus,
then interrupted 6–0 silk beginning at gray line. Avoid
suture contact w/ cornea, and ensure wound eversion to
avoid notching at lid margin
• Lacrimal apparatus: evaluate if medial eyelid injured,
then cannulate punctum w/ lacrimal probe
• Manage injury with Crawford tube (silastic) stenting for
4 weeks. If unable to cannulate, repair laceration; late
stenosis/epiphora may require dacryocystorhinostomy
– Ear
• Cartilage: preserve if perichondrium intact, otherwise
débride
○ Bolster skin repair with petroleum/Xeroform gauze to
prevent hematoma formation
• Hematomas require evacuation and bolster dressings
– Nose: assess and repair separately the skin/soft tissue,
cartilage, and mucosa
• Skin: 6–0 permanent suture
• Cartilage: 5–0 monofilament (resorbable)
• Mucosa: 4–0 chromic
– Lip: Mark white roll with methylene blue before infiltrating
with anesthetic, then approximate orbicularis oris, followed
by vermillion. Finally, layered closure of other epidermis and
mucosa is accomplished
– Tongue: 3–0 chromic sutures with buried knots effectively
appose mucosa after more durable resorbable suture (i.e.,
Vicryl®) is used to approximate deeper tissue

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 Head and Neck 37

– Parotid duct (avoid cutaneous fistula or sialocele)

• Cannulate Stensen’s duct (opposite maxillary second molar)
w/ 24-g angiocatheter
• Irrigate duct gently w/ saline and observe for extravasa-
tion (if extravasates → microsurgical repair)
• Silastic stents of questionable benefit
• Note: submandibular duct lacerations can be marsupial-
ized onto floor of mouth
– Facial nerve: check CN VII function before instilling anesthetics
• If laceration is medial to line from lateral canthus to cor-
ner of mouth, nerve has extensively arborized and func-
tion will be minimally affected
• If laceration is lateral to this line, repair w/in 72 hours to
allow use of intraoperative nerve stimulation
c. General reconstructive considerations
i. Before embarking on reconstruction, clean, STABLE wound bed
must be ensured
ii. Especially in the face, defining the missing elements is critical
in planning an appropriate reconstruction
– Many defects can be broken down into some combination of
deficits of:
• Soft tissue cover
• Lining
• Structural support
iii. Each of these elements must be replaced to prevent ongoing or
worsening functional loss or cosmetic deformity
d. Local flaps
i. Tongue flap: based on lingual artery; can be based proximally or
distally; good for small intraoral defects or to reconstruct red
vermillion
ii. Nasolabial flap: based on facial/angular artery; can be proxi-
mally or distally based; useful for cutaneous defects of upper
lip, nose, and lower eyelid
e. Axial flaps
i. Forehead (temporal) flap: based on supratrochlear artery; can
be used to reconstruct entire nasal skin envelope and a small
portion of nasal lining
ii. Superficial temporal artery fascial flap: thin, pliable flap; useful
for coverage of ear reconstruction or dorsal hand defects
iii. Temporalis muscle flap: based on anterior and posterior tempo-
ral arteries; useful for intraoral reconstruction, orbital recon-
struction, and for dynamic facial reanimation
iv. Deltopectoral flap: based on thoracoacromial artery; extended
flaps have random pattern component; can resurface skin defects
of the lateral face/head with back-grafting of donor defect
v. Masseter muscle flap: based on masseteric artery (off STA);
used mainly for dynamic facial reanimation

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f. Musculocutaneous flaps
i. Pectoralis major flap: based on thoracoacromial artery for head
and neck reconstruction; can provide muscle or skin coverage
for anterior and lateral defects of the lower 1⁄3 of the face
ii. Latissimus dorsi flap: based on thoracodorsal artery; can provide
pedicled coverage for lower facial defects or be used as a free
flap to cover large scalp defects (in conjunction with skin grafts)
iii. Trapezius flap: based on transverse cervical artery for head and neck
reconstruction; can provide coverage of the lower third of the face
g. Free tissue transfer: becoming the workhorse of head and neck
reconstruction
i. Anterolateral thigh (ALT) flap
ii. Radial forearm flap
iii. Rectus abdominis flap
iv. Latissimus dorsi flap
2. Nose
a. Nine aesthetic subunits (Burget GC, Menick FJ, Plast Reconstr Surg.
1985 Aug;76(2):239–47)
i. Dorsum
ii. Tip
iii. Columella
iv. Sidewalls (2)
v. Alae (2)
vi. Soft triangle (2)
b. Nasal lobule composed of: tip, alae, nostril sills, and columellae
c. General rules:
i. Place incisions along borders of adjacent subunits when possible
ii. If defect >50% of subunit, excise remainder and reconstruct
entire subunit
iii. When available, use undamaged contralateral subunit as
model for reconstruction
iv. Divide large defects into multiple subunits, and address each
with a separate graft or flap for best aesthetic results
– Defects should be assessed for missing components*:
• Skin
• Structural support
• Mucosal lining
*Each component must be replaced
– Nonanatomic placement of cartilage grafts for support will
bolster large reconstruction from contractile forces during
the healing process and prevent secondary deformities
– Nasal dorsum and sidewalls
• Banner flap: good for defects <1.2 cm
• Bilobed flap: for lateral defects <1.5 cm; flaps remain
medially based to prevent using cheek skin
• Dorsal nasal flap: for lower dorsum, supratip lobule (at
least 1 cm from alar rim); can close up to 2-cm defects

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 Head and Neck 39

– Ala
• Nasolabial flap: can reconstruct entire alar subunit; will
need nonanatomic cartilage grafts for support
– Tip
• Small tip defects (<1 cm) can be closed with full-
thickness skin graft (FTSG), although cosmetic defect
will be noticeable
• Paramedian forehead flap most useful for tip and colu-
mella reconstruction
• Must stage flap and provide nonanatomic cartilaginous
support to prevent unsightly scar contracture
– Mucosa
• Turnover flap: incising margin of healed wound and turn-
ing skin in to recreate mucosal lining; good for small
defects
• Mucosal “buckethandle” flap: bipedicled flap of intra-
nasal mucosa advanced into alar/caudal defect; donor
defect resurfaced with an FTSG
• Septal mucosal flap: septal mucosa from contralateral
nasal airway elevated and passed through septal incision
to line ipsilateral airway
• Ipsilateral septal mucosa can be elevated based on septal
branch of superior labial artery and rolled on itself for lining
– Support
• Strut: bone or cartilage graft anchored to radix (K-wire or
screw fixation) to give dorsal support; can be combined
with columellar strut for total support of nose; referred to
as a cantilever graft if columellar extension not used
• Septal flap: septum (L-shaped) is hinged superiorly to
augment nasal dorsum
• Anatomic cartilage grafts: cartilage (septum, concha,
rib) used to replace nasal cartilages
• Nonanatomic cartilage grafts: used to lend support to
existing cartilages to resist scar contracture
○ Alar batten graft: placed cephalad to alar rim; support
external nasal valve but do not correct alar notching
○ Alar contour graft: placed along alar rim; provides har-
monious alar contour
○ Lateral crural strut: placed deep to lower lateral carti-
lage and extends to piriform aperture; helps reposition
lower lateral cartilages and resist alar collapse
○ Spreader graft: placed between dorsal septum and
upper lateral and lower lateral cartilage; prevents/
treats internal nasal valve collapse; can treat pinched
tip deformities

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 40 Head and Neck

3. Oral cavity
a. General: tend to be complex defects with poor functional outcomes.
Goals are to allow for passageway for food and air, and to provide
tongue bulk for swallowing and speech function
b. Floor of mouth/tongue: goal of reconstruction is to provide bulk to
obliterate dead space when speaking or swallowing. Options include
pedicled pectoralis, free rectus, or free ALT flaps
c. Soft palate: thin flaps can provide closure of defect but are non-
functional (free radial forearm flap, pedicled temporalis flap); con-
sider palatal prosthetics as an option
d. Hypopharynx and esophagus: small defects with adequate
mucosal lining can be closed primarily. Circumferential or near-
circumferential defects merit reconstruction. Flaps include:
i. Pedicled, tubed pectoralis
ii. Free tubed radial forearm
iii. Free tubed ALT (this is becoming the workhorse for cervical
esophageal/laryngeal reconstruction)
iv. Free jejunum
v. Long segment; more distal reconstructions will require a gas-
tric pull-up or colonic interposition
4. Mandible
a. General: planning on the size of the defect is critical in planning a
reconstruction, with respect to both bone and soft tissue
b. Nonvascularized bone grafts: adequate for <6 cm defects with
healthy soft tissue envelope. Iliac crest is preferred donor site. May
not have enough bone stock for later dental implant placement. No
ability to provide missing soft tissue elements
c. Sterilized autogenous bone
d. Alloplasts: titanium reconstruction bar can span a bony defect, but
will fracture with time (~6–9 months); good for patients as part of
a staged reconstruction or in those with limited life expectancy
e. Vascularized bone: necessary when bony defect >6 cm or for central
mandibular defects (involving symphysis and both parasymphyseal
regions)
f. Composite mandibular defects
i. Free fibula is donor site of choice
ii. Radial forearm flap provides excellent thin soft tissue coverage;
bone stock generally not amenable to later implant placement
iii. Free scapula flap provides excellent soft tissue bulk; bone stock
generally not amenable to later implant placement
g. TMJ reconstruction: difficult to restore complex functional proper-
ties of a native TMJ via any method
i. Numerous methods of TMJ reconstruction; need to recreate
cartilaginous surface of glenoid fossa for adequate rotation
and translation of joint complex
– Vascularized rib: used primarily in younger patients (9–10 yr)
with severe mandibular hypoplasia (hemifacial microsomia);
has a tendency to become hyperplasic after transplantation

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 Head and Neck 41

– Distraction osteogenesis: upward distraction of a vertical

ramus segment will cause cartilaginous cap to form
– Alloplastic reconstruction: historically high failure rate
with Teflon or silicone implants, newer implants’ longevity
controversial
5. Complex midfacial defects
a. These are challenging defects that require some combination of
skin, bone, and mucosal reconstruction
b. Reconstructions planned on an individual basis, and computer-
assisted design techniques now becoming routine in operative
planning and execution
c. Goals are to provide for patent airway, adequate bone stock for
implant-based dental prosthetics, and acceptable long-term
cosmesis
d. Local tissue rearrangement can be used to close smaller defects,
but most large composite defects will require a free tissue
transfer
e. Best results are obtained when goals are met in a staged fashion
(“You don’t hit a home run with the first surgery—just get on base.”)
f. Useful free flaps include:
i. Free rectus abdominus
ii. Free fibular osteocutaneous flap
iii. Free ALT
iv. Free radial forearm (fascio- or osteocutaneous)
v. Free deep circumflex iliac artery (DCIA) flap
vi. Free scapular or parascapular flap (fascio-or osteocutaneous)
vii. Pedicled pectoralis major or temporalis flaps
6. Lips
a. Goals of lip reconstruction: provide for oral competence and rees-
tablish sphincteric muscular integrity
i. Recreate cosmetic anatomic landmarks and subunits
b. Vermillion deficiency: notching or a small defect can be closed by
V-Y advancement of intraoral mucosa
i. Larger defects (up to 50%) will require vermillion sharing
(cross-lip flap) or axial musculovermillion advancement flaps
ii. 50–100% defects require a tongue flap, intraoral mucosal
advancement flaps, or facial artery musculomucosal (FAMM)
flaps
c. Full-thickness reconstruction: primary closure by wedge excision
and advancement for defects <1/3 total lip length
i. Upper lip: wedge excision of perialar crescents will allow for
closure
ii. Lower lip: resulting skin excess removed from labiomental crease
iii. 1/3 – 2/3:
– Upper lip: Abbé flap (lip switch) from lower lip to labiomen-
tal crease
• design flap 1 /2 -width of defect

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 42 Head and Neck

– Lower lip: Karapandzic flap or Webster-Bernard flap

• Skin excess removed from nasolabial creases and labio-
mental crease
iv. Total lip defect: free flap (radial forearm) with palmaris longus
tendon interposition between modiolus to provide barrier func-
tion and prevent incompetence
7. Eyelid
a. Goals of reconstruction: provide coverage for globe to prevent des-
iccation of the cornea and protection from the environment
i. Key to successful reconstruction is identification of missing
elements:
– Anterior lamella = skin and orbicularis oculi muscle
– Posterior lamella = tarsal plate, levator musculature (upper
lid)/capsulopalpebral fascia (lower lid), and conjunctiva
b. Partial thickness defects
i. Skin: can be closed primarily or closed with full-thickness skin
graft from contralateral upper eyelid (other donor sites:_ pre-/
postauricular skin)
ii. Conjunctiva: adjacent tissue can be advanced to fill small
defects
– Buccal/nasal mucosa for larger defects. DO NOT use
skin grafts; these are keratinized and will cause corneal
irritation
c. Full-thickness defects: reconstruction based on amount of lid tis-
sue missing
i. Up to 25%: defects can be closed primarily via pentago-
nal excision (DiFrancesco LM, et al., Plast Reconstr Surg,
2004;114(7):98e–107e)
ii. 25–40%: defects can be closed primarily with the addition of a
lateral canthotomy
iii. 40–75%: addition of laterally based semicircular rotation flap
(Tenzel flap) allows for primary closure of defect
– Upper lid defects can also be closed by advancement of full-
thickness upper lid (Cutler-Beard flap), sparing lid margin,
and tarsal plate
– Lower lid defects: for Hughes flap, tarsoconjunctival
advancement with FTSG (Rohrich RJ, Zbar RI, Plast Reconstr
Surg, 1999;104(2):518–22)
iv. 75–100%: require separate anterior and posterior lamella
reconstruction
– Upper lid: paramedian forehead flap or temporal forehead
flap for anterior lamella
– Lower lid: bipedicled upper-eyelid skin flap (Tripier flap) or
cheek advancement flap for anterior lamella
• Palatal mucosal grafts (mucoperiosteal) will provide
mucosal lining and support for posterior lamella

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 Head and Neck 43

• Thick flaps such as the forehead flap can be lined with

mucosa (buccal/nasal) and have conchal cartilage grafts
inserted in a delayed fashion
• Allograft (acellular dermal matrix) can be used for tarsal
reconstruction, but requires healthy soft tissue envelope
for vascularization
8. Ear
a. Helical and upper-third defects
i. Wedge resection: star-shaped resection pattern may help avoid
buckling; direct closure possible for up to 1.5-cm defect
ii. Antia-Buch technique: rim advancement useful for superior
helical defects. Incise along rim through anterior skin, peri-
chondrium, and cartilage of entire helical rim, undermining
posterior skin. Rim can advance to close defect (can perform
V-Y closure of helical root for added advancement)
– Good for defects up to 3 cm
iii. Converse tunnel procedure: useful for defects >3 cm
– First stage: harvest cartilage strut, place in postauricular
subcutaneous pocket, and sew to margins of rim defect
– Second stage: elevate cartilage strut along with skin to
complete reconstruction; close retroauricular donor site by
advancement or skin graft
iv. Tubed pedicle flap
– First stage: fashion thin tube of retroauricular skin from
bipedicled skin flap
– Second stage: one end of tubed flap elevated and inset into
defect
– Third stage: inset of flap completed
b. Middle-third defects
i. Postauricular (Dieffenbach) flap: plan a postauricular flap
based on edge of hairline, with width equal to defect width and
adequate length to reconstruct anterior surface, rim, and pos-
terior surface
– First stage: raise flap down to postauricular fascia and
suture free margin of flap to anterior free skin edge of defect
– Second stage (14–21 days later): divide flap, use it to
reconstruct posterior ear
c. Lower-third defects
i. Soft, flexible tissue generally provided by local flaps folded over
on themselves. To provide more support and contour, contralat-
eral conchal grafts can be placed subcutaneously
d. Total ear defects
i. Contralateral costal cartilage harvested and carved into
framework (synchondrosis of sixth to eighth ribs, ninth floating
rib used as helical rim as needed)

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 44 Head and Neck

ii. Cartilage then placed in subcutaneous pocket (in cases of con-

genital microtia/anotia) or covered with temporoparietal fascia
flap and unmeshed skin graft
iii. Consideration must be given to osteointegrated implant-based
prosthetic if patient is of advanced age, has numerous medical
comorbidities, or has inadequate local tissue coverage options

D. TRAUMA
1. Facial fractures
a. General: approximately 11% of trauma patients sustain maxillofa-
cial injuries requiring intervention (Girotto JA, et al., Plast Reconstr
Surg, 2001;108(2):312–27); evaluate for brain, spine, ophthalmo-
logic injuries
b. Physical exam
i. Inspect for contusions, lacerations, edema, hematoma (i.e.,
septal), asymmetries, and visible deformities
ii. Palpate the horizontal and vertical buttresses of the face for
step-offs
iii. Check for midface stability
iv. Gross visual exam
v. Assess occlusion
c. Radiography
i. CT maxillofacial region
– Axial, coronal, +/– sagittal views (thin cuts 1.0–1.5 mm)
– Assess integrity of horizontal and vertical buttresses (these
are the thickest portions of the bone where plate fixation
must be placed during repair)
– Categorize facial fracture patterns (i.e., LeFort level, zygo-
maticomaxillary complex, orbital, mandible, pan facial, etc.)
ii. Frontal sinus: recommend Rodriguez ED, el al., Plast Reconstr
Surg, 2008;122(6):1850–66
– General
• Frontal bone requires greatest force to fracture relative to
any facial bone
• FS fractures are associated with other significant inju-
ries about 75% of the time, including nasoorbitoethmoid
(NOE) fx
• Isolated anterior table fx 33%, combined fx 67%, isolated
posterior table fx rare
• Posterior table fx can be associated with cerebrospi-
nal fluid (CSF) leak (therefore, consider neurosurgery
involvement for evaluation if severe fx or leak)

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 Head and Neck 45

– Presentation
• Suggestive sx include: upper facial edema/ecchymoses,
diplopia, forehead hematoma/abrasions, epistaxis, supra-
trochlear/supraorbital paresthesias
• CSF rhinorrhea (ask about “salty” post nasal drip): check
“halo” test, fluid glucose, a/o beta2-transferrin
○ Review CT scan for involvement of anterior and poste-
rior table fractures and severity, proximity to nasofron-
tal ducts, pneumocephalus
– Treatment
• Options (depending on findings) may include observation,
ORIF, sinus obliteration, or sinus cranialization.
• Surgical exposure via coronal flap, or, for isolated anterior
table fx, may consider going through frontal lacerations
○ Anterior table fx
• ORIF: if significant contour irregularity exists, use mini-
plast for anterior table fixation
• Alternately, consider cyanoacrylates for thin bone fragments
• Consider possibility of nasofrontal duct injury
○ Jones test
■ Jones test I: stain corneal tear film with 2% fluorescein
dye, then check for stain under inferior turbinate with
cotton swab 5 min later. If cotton swap stains, then
patency of nasolacrimal duct assured; negative test
means possible duct block
■ Jones test II: if above test results in no dye found
from inferior turbinate, irrigate lower canaliculus
with saline. If dye can be recovered from inferior
turbinate, indicates partial or functional block
• Frontal sinus obliteration for anterior table fracture
involving the nasofrontal ducts
○ Remove all mucosal lining to prevent mucocele
○ Obliterate of duct and sinus with cancellous bone grafts
and/or vascularized soft tissue (i.e., pericranial flap)
○ Avoid free fat and muscle grafts as they risk necrosis
and resorption
• Isolated fractures around the duct may be appropriately
treated with stenting or dilation of duct
○ Posterior table fx
• Cranialization: appropriate if anterior and posterior table
fractures are significantly displaced, CSF leak, posterior
table comminution
○ Perform in conjunction with neurosurgeon
○ Facilitates inspection (and repair) of dura and naso-
frontal duct
○ Use coronal approach for craniotomy, then remove
posterior table and sinus mucosa

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 46 Head and Neck
○ Occlude nasofrontal duct with cancellous bone graft
and pericranial flap
– Complications of FS fractures and/or repair
• Acute: CSF leak, meningitis, brain injury, epistaxis (may
require interventional radiology to control)
• Chronic: osteomyelitis, mucoceles, abscess (intracranial a/o
orbital), contour irregularity, chronic sinusitis, mucopyelocele
2. Zygoma fractures
a. AKA malar fracture, zygomaticomaxillary complex (ZMC) fracture,
orbitozygomatic (OZM) fracture
b. Zygoma has four bony connections (frontal, maxillary, sphenoid,
temporal)
c. All four articulations need to be fractured to lead to zygoma insta-
bility and displacement (“tetrapod” fracture)
d. Presentation
i. Exam: midface edema, infraorbital nerve paresthesia, malar flat-
tening, downsloping lateral canthus (antimongoloid slant), tris-
mus, step-off along the orbital rims, zygomatic arch, ZM buttress
– Complete ophthalmologic exam required, including acuity
and extraocular muscle function
ii. Review CT scan for:
– Comminution of articulations
– Rotation and alignment of body of zygoma
– Position of the lateral orbital wall
– Involvement of the orbital floor
– Fracture pattern along zygomatic arch (location of frac-
tures, microfractures, displacement)
– Evaluate for hemi-NOE fracture associated with ZMC
e. Management
i. Minimally displaced fractures can be treated with simple open
reduction technique (i.e., Gillies’ maneuver, reverse Gillies’, or
Dingman maneuver)
ii. Most displaced fractures require ORIF
iii. Need to stabilize at least three of the four articulations
iv. Reduction of zygoma most importantly assessed by reduction
of the lateral orbital wall (zygomatic-sphenoid reduction)
v. Surgical approach
– Anterior versus posterior approach dependent on the posi-
tion and comminution of the zygomatic arch
– Need to open and stabilize the arch if the zygomatic arch is
laterally displaced or comminuted
– Anterior approach (lateral upper bleph incision, lower eyelid
incision (transconjunctival versus subtarsal), upper sulcus
incision
• No need to open and stabilize the zygomatic arch if micro-
fractured and medially displaced

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 Head and Neck 47

– Posterior approach (coronal incision, lower eyelid incision,

and upper sulcus incision)
– Coronal approach required for arch exposure
f. Isolated zygomatic arch fractures is mostly an aesthetic concern for
palpable and/or visible contour deformity
– May result in trismus if depressed and impedes coronoid
during mandible excursion
– These can be reduced via a Gillies’ maneuver, reverse Gillies’
maneuver, or Dingman maneuver
g. Complications of zygoma fractures and/or repair
i. Diplopia
ii. Enophthalmos
iii. Traumatic optic neuropathy
iv. Infraorbital nerve anesthesia/hypesthesia
v. Bradycardia (oculocardiac reflex)
vi. Malar soft tissue ptosis
3. Orbital fractures
a. Anatomy
i. Bony orbit made up of seven bones (frontal, sphenoid [greater
and lesser wings], zygoma, maxilla, ethmoid, palatine, lacrimal)
ii. Thinnest bone in the orbit is the ethmoid bone (medial wall).
The lamina papyracea of the ethmoid sinus acts as a buttress
and can resist fracture
iii. Most common site of fracture is the orbital floor
b. Mechanism of injury
i. Hydraulic theory versus bone conduction theory (Waterhouse N,
et al., Br J Plastic Surg, 1999;52:607–12)
c. Orbital floor (blowout) fractures
i. Presentation: diplopia, enophthalmos, exophthalmos, orbital
emphysema, periorbital edema, ecchymosis, infraorbital nerve
paresthesia
ii. Obtain ophthalmology exam to check for acuity, globe injury
(about 30% of orbital fractures will have some kind of ocular
injury)
iii. Ocular injuries
– Corneal or scleral lacerations, lens dislocation, hyphema,
acute glaucoma, retinal detachment, globe rupture, retro-
bulbar hematoma
iv. Treatment
– Indications for surgery
• Orbital floor defect >2 cm (or 1 cm2)
• Diplopia
• Dystopia/enophthalmos
• Limited eye excursion
○ Entrapment of inferior rectus: rare in adults, more
common in children as orbital floor bone less stiff,
recoils more

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 48 Head and Neck

v. Timing
– When periorbital edema subsides (no urgency for repair,
unless there is true entrapment)
– Urgent repair indicated (24–48 h) for true trapdoor fracture
with entrapment
• May present with pain with attempted eye movement,
bradycardia (oculocardiac reflex), or nausea and vomit-
ing (oculogastric reflex)
– Ocular/globe injury is contraindication for early surgery
(i.e., hyphema aggravation may cause acute closed-angle
glaucoma)
– Retrobulbar hematoma: emergent orbit decompression with
a lateral canthotomy at bedside
vi. Surgical approach
– Access to the orbit is provided via a lower eyelid incision
– Transconjunctival or subtarsal incision
– Transconjunctival incision can be performed with a presep-
tal or retroseptal dissection
– Can combine with lateral canthotomy to increase exposure
(canthus needs to be repaired during closure)
– Combine transconjunctival with a retrocaruncular extension
for improved access to the medial wall if necessary
– Subciliary incision has highest risk for ectropion
vii. Materials for orbital floor and/or medial wall fractures
– Bone graft
• Alloplastic implants
○ Titanium mesh
○ MEDPOR (high-density porous polyethylene)
• Polyethylene
○ Resorbable implants (best for pediatric patients and
small defects)
○ Silastic
d. Blow-in fractures
i. Rare, can occur with intraorbital displacement of the lateral
wall, may cause impingement of lateral rectus
ii. Treated with simple reduction of the lateral wall segment
e. Orbital roof fractures
i. Rare, may present with proptosis and diplopia, most small
fractures can be left untreated
ii. Repair if large defect and persistent diplopia
iii. Uncomplicated fractures can be reduced via upper blepharo-
plasty incision and roof reduction
iv. May need frontal craniotomy and skull base reconstruction with
split calvarial bone graft for complex injuries
v. Large unrepaired defects can result in persistent exophthalmos
and pulsatile proptosis

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 Head and Neck 49

f. Complications of orbital fractures or repair

i. Retrobulbar hematoma, implant migration, infection, diplopia,
enophthalmos, infraorbital hypoesthesia, epiphora, vertical dystopia
or other globe asymmetries, ectropion, entropion, traumatic optic
neuropathy, superior orbital fissure, and orbital apex syndrome
4. Nasal fractures
a. Most common fracture of facial bones
b. Often associated with septal fractures and deviation
c. Clinical diagnosis; CT scan not needed for isolated nasal bone
injuries
d. Presentation
i. Nasal deformity
ii. Nasal edema
iii. Nasal bone crepitus
iv. Epistaxis
v. Septal deviation
vi. Septal hematoma (this must be drained urgently to avoid septal
necrosis and secondary nasal tip support deformities)
e. Treatment
i. Reduction of nasal bone and septum within 5 days preferably
Recommend: Rohrich RJ, Adams WP Jr., Plast Reconstr Surg,
2000;106(2):266–73
5. NOE fractures
a. One of the most difficult facial fracture patterns to repair
b. Anatomy: NOE complex is confluence of nasal, lacrimal, ethmoid,
maxillary, and frontal bones
i. Three buttresses
– Vertical buttress: nasofrontal and nasomaxillary buttresses
– Horizontal buttress: inferior orbital rim
– Destabilizing fractures of these buttresses will result in
NOE complex fracture
ii. Medial canthal tendon (MCT): originates at anterior/posterior
lacrimal crests and frontal process of maxilla
– Envelops lacrimal sac then splits laterally to form pretarsal,
preseptal, and orbital orbicularis muscles
– Normal intercanthal distance 30–35 mm (~½ of nl interpu-
pillary distance)
c. Presentation: telecanthus, saddle nose. Avulsion of medial canthus
can occur
i. Ophthalmology consult mandatory for globe assessment
d. Classification
i. Markowitz (Manson PN, Markowitz B, et al., Plast Reconstr Surg.
1990 Feb 85(2):202–12)
– Type I: single, noncomminuted central fragment w/o MCT
disruption
– Type II: comminuted fx w/o medical canthus avulsion
– Type III (rare): comminuted fx w/ medial canthus avulsion

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 50 Head and Neck

e. Exposure to the NOE complex

i. Coronal incision: access to nasofrontal buttress and medial
orbital wall
– Useful for complex NOE fractures (i.e., Types II and III)
ii. Lynch incision: access to nasofrontal buttress and medial
orbital wall
– Useful for simple NOE fracture (Type I)
iii. Lower eyelid incision (subtarsal or transconjunctival): access
to infraorbital rim
iv. Upper sulcus incision: access to nasomaxillary buttress
f. Treatment
i. Goals of repair are to reestablish intercanthal distance, restore
nasal projection, and repair intraorbital defects
ii. Type I
– Nondisplaced, single fragment: treat nonoperatively
– Displaced: miniplate fixation of two to three buttresses
• Lynch incision or coronal for access to nasofrontal buttress
iii. Type II
– Will need coronal incision in addition to lower eyelid, +/–
upper sulcus
– Miniplate fixation of bony fragment containing canthal ten-
don up to stable frontal bone after anatomic reduction
– May need transnasal wiring if unable to stabilize medial
canthal segment with miniplate
– May need cantilever bone graft to nose if nasal support
compromised
– Stabilize septal fracture if present
iv. Type III
– Coronal incision absolutely necessary for wide exposure
– Reconstitute intercanthal distance with transnasal wiring
or medial canthal tendon canthoplasty techniques
– Cantilever bone graft for dorsal nasal reconstruction and
tip support
– Stabilize septal fracture if present (may need delayed
septoplasty after 6–12 months if nasal airway obstruction
develops)
g. Complications of fracture and/or treatment: telecanthus, lacrimal
disruption, blindness, enophthalmos, midface retrusion, anosmia,
CSF fistula, epiphora, nasal deformity (i.e., saddle nose deformity),
sinusitis, nasal airway obstruction
6. Maxillary fractures
a. Maxilla is the largest bone of the midface, contains maxillary sinus
and dentition
b. Anatomy
i. Three supporting vertical buttresses on each side
– Anterior: nasomaxillary and zygomaticomaxillary
– Posterior: pterygomaxillary

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 Head and Neck 51

c. Presentation
i. Midface and/or periorbital edema
ii. Epistaxis
iii. Malocclusion (typically anterior open bite)
iv. Midface instability may be present (if severe impaction of max-
illa, the midface may clinically feel stable)
d. Fracture patterns
i. Dentoalveolar: involvement of teeth and supporting structures
ii. Palate fracture
iii. LeFort fractures: need disruption of pterygoid plates and ante-
rior buttresses to destabilize the maxilla
– LeFort I: transverse fracture across maxilla
– LeFort II: pyramidal fracture to include nasal bones as
disjunction occurs through medial orbit and nasofrontal
suture
– LeFort III: complete craniofacial disjunction as fractures
across zygomatic frontal suture, through orbits and zygo-
matic arch
e. Treatment
i. Goals of repair are to restore pretraumatic occlusion
ii. Exposure dependent on fracture type: incisions can include
upper sulcus, or lower, upper, or coronal eyelid
iii. Dentoalveolar fractures are stabilized with arch bar across
maxillary arch
iv. Palate fractures can be stabilized with horizontal miniplate
across the fracture line along the lower maxilla. Combine with
arch bars and elastics to maintain appropriate occlusion
v. ORIF for LeFort fractures
vi. Maxillary disimpaction and placement in MMF necessary prior
to plate fixation of anterior buttresses
vii. Primary bone graft to buttresses if bony gaps exist due to
comminution
viii. Consider postoperative elastics for several weeks to maintain
occlusion
f. Complications of maxillary fractures and/or repair: malocclusion
and maxillary malposition
7. Panfacial fractures
a. Fractures of the upper face, midface, and mandible
b. Multiple surgical approaches will be required (coronal incision for
access to upper skeleton and zygomatic arches)
c. ORIF necessary moving from stable regions to unstable
i. Can perform top-down or bottom-up approach (start with fixa-
tion from the most stable peripheral bone)
d. Goals of reconstruction are to restore occlusion, and to reestablish
normal facial width and height and projection

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 52 Head and Neck

e. Anatomic mandibular fixation necessary to allow for midface recon-

struction and occlusal correction
i. If bilateral condylar segments fractured, need to open at least
open side to reestablish vertical height of the mandible
f. Anatomic reduction and stabilization of zygomatic arches will
establish appropriate facial width
g. Stabilization across the LeFort I level should be the last maneuver
in sequence
8. Mandibular fractures
a. General
i. Fractures of the mandible are described by anatomic region
b. Presentation
i. Malocclusion (i.e., crossbite, anterior open bite)
ii. Lower facial edema and ecchymoses
iii. Intraoral ecchymoses
iv. Mental nerve parasthesias
c. Diagnosis
i. Clinical exam
– Inspect occlusion
– Check for broken or loose teeth
– Inspect for intraoral laceration and gingival tears
– Assess range of motion of jaw and look for TMJ issues
ii. Radiology
– Panorex
• Single best X-ray modality as a single film (can have lim-
ited view of the condylar regions)
– Mandible series (AP, lateral, lateral oblique, Townes view)
– CT scan (usually easiest to obtain since head and facial
trauma patients usually go to the scanner routinely for head
and c-spine, etc.)
d. Principles of management
i. Antibiotic indicated as most fractures are open
ii. Higher risk of infection and nonunion in mandible fractures
relative to midface fractures (due to pooling of saliva)
iii. Biomechanical stresses on the mandible occur from the muscle
of mastication
– Tensile and compression stresses
– Need to be neutralized to achieve stability and optimize union
iv. Methods of fixation
– Use tension band and stabilization plate for most fractures
involving the body, parasymphysis, and symphysis
v. Tension band stabilization
– Arch bars can function as tension band; however, can be
unreliable because interdental wires loosen with time
– Optimal stabilization with monocortical plate just inferior to
the alveolar border (neutralizes the tension forces)

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 Head and Neck 53

– Second larger bicortical plate along the inferior border

(neutralizes the compression and torsion stresses)
vi. Champy’s principles for ORIF with miniplates (Champy M, and
Kahn JL, J Oral Maxillofac Surg, 1995;53:801–2)
– Miniplates can be anchored with monocortical screws (no
compression necessary)
– Anterior to canines, 2 miniplates are needed to control rota-
tional forces of genial and digastric muscles
– Posterior to canines, only 1 miniplate is required. Single
2.0-mm noncompression miniplate associated w/fewer com-
plications than double-plate fixation (Ellis E 3rd, Int J Oral
Maxillofac Surg, 1999;28(4):243–52)
vii. Definitions of stability
– Rigid stability
• No movement across the fracture gap
• Most optimal fixation principle
– Functional stability
• Small acceptable movements allowed along the fracture
gap
• Load-sharing: functional stability achieved by fixation
system in conjunction with stabilizing forces provided by
the alignment of the fracture and muscles (i.e., Champy
technique)
• Load-bearing: functional stability provided solely by the
fixation system (i.e., rigid fixation)
viii. Treatment
– Goals of treatment are to restore pretraumatic occlusion
and preservation of teeth
– Condylar fracture
• Difficult surgical access due to the facial nerve
• Most condylar head fractures (intracapsular) should be
treated nonoperatively with early ROM
• Pediatric condyles will remodel and children respond very
well to nonoperative management
• Fracture w/o malocclusion: soft diet and observation
• Fracture with malocclusion: closed reduction with func-
tional MMF
– Subcondylar fracture
• Access via preauricular incision, retromandibular incision,
or Risdon incision
• Be mindful of the facial nerve
• ORIF with single miniplate (not much space on the sub-
condylar segment available for plating to extracapsular)
• Early range of motion indicated after ORIF
– Angle fracture
• Access via intraoral incision with cheek stab incision and
trocar assistance as needed

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 54 Head and Neck

• Champy technique
• Monocortical angle plate
• Inferior border plate +/– monocortical plate (easier via
external Risdon incision)
– Mandibular body fracture
• Access via intraoral lower sulcus incision (identify
and preserve the mental nerve, which exists near the
premolars)
• Optimal treatment with a two-plate technique (tension
band and stabilization plate)
• Consider stab incision and trocar assist to help with
placement of inferior border plate
– Parasymphyseal fractures
• Access via lower sulcus incision
• Optimal treatment with a two-plate technique (tension
band and stabilization plate)
– Symphyseal fractures
• Access via lower sulcus incision
• Optimal treatment with a two-plate technique (tension
band and stabilization plate)
• May also consider stabilization with two lag screws
e. Pediatric mandible fractures
i. Condyle is growth center for (primarily) vertical growth
ii. Generally remodel, but fracture can cause growth disturbance,
ankylosis, and hypoplasia
iii. If no malocclusion: soft diet and early range of motion
iv. If malocclusion: consider functional MMF for 1–2 weeks
v. Difficult to place children in arch bars given that primary teeth
are short and there are often missing teeth in mixed dentition
vi. Tooth buds in mandible limit options for internal fixation
vii. Use only monocortical screws
viii. Consider resorbable plates and screws
ix. Fracture healing is faster in children, therefore, can treat with
MMF for shorter period of time (2–4 weeks versus 4–6 weeks in
adults)
f. Edentulous patients
i. Lack of dentition and poor bone stock
ii. Decreased healing capacity
iii. Favor external approaches and less periosteal stripping (place
plates in the preperiosteal plane for improved reduction and
maintenance of microcirculation to the bone)
iv. Use large plates (i.e., reconstruction plates); miniplates and
small plates contraindicated
v. May need to use primary bone grafts in the severely atrophic
mandible

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 Head and Neck 55

E. TUMORS
1. Epidemiology
a. 3–5% of all new cancer diagnoses in the United States each year
b. Oral cavity: one location for head and neck cancer
i. 59% overall 5-year survival
– Early lesions >85% survival
– Late stage <25% survival
– 66% of oral cancer patients present with advanced disease
ii. 92% of oral cancer patients are over 40 (avg. 63) (Horner MJ, et
al., SEER Cancer Statistics Review, 1975–2006, National Cancer
Institute, Bethesda, MD, based on November 2008 SEER data
submission, posted to the SEER web site, 2009)
2. Oropharyngeal tumors
a. Etiology: smoking (most important; cessation for 10 years decr. risk
50%), EtOH (synergistic with tobacco, risk if >50 g/day), HPV, betel
quid, UV/sun overexposure
i. 25% of all oral cancer victims have no identifiable risk factors
b. Location
i. Lesions of concern
– Leukoplakia: white patch that cannot be rubbed off; located
on floor of mouth >> lateral tongue, lower lip > other
• DDx: hyperkeratosis +/– dysplasia, carcinoma in
situ, invasive carcinoma, lichen planus, Candida, etc.
Majority without dysplasia (Bornstein MM, et al., Schweiz
Monatsschr Zahnmed, 2004;114(7):680–6)
– Erythroplakia: red plaque, often velvet in appearance.
Located on floor of mouth > soft palate/anterior tonsillar
pillar/retromolar trigone > lateral tongue. >90% severe
dysplasia, CIS, or invasive carcinoma
c. Diagnosis
i. Head and neck exam: sensitivity ~60%, specificity 98%
– Sites: skin of head and neck
• Neck: lymph nodes, salivary glands, carotid, thyroid,
other masses
• Oral cavity, oropharynx: visualize all mucosa, palpate the
tongue, lips, cheek, and floor of mouth
• Nose, nasopharynx
• Larynx: can use mirror or flexible nasopharyngoscopy
ii. Tissue: scraping/cytology, FNA, biopsy (incisional/excisional)
iii. Imaging: CT, MRI, PET

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TABLE 2.4 Oral Cavity Cancer Staging

T1: <2 cm N1: 1 ipsilateral node M0: No distant metastasis

<3 cm

T2: <2 , but >4 cm N2a: 1 ipsilateral node M1: Distant metastasis
>3, but <6 cm

T3: >4 cm N2b: multiple ipsilateral Distant metastasis –

nodes <6 cm metastatic oral cavity
SCCa is currently
considered incurable

T4: invades bone, N2c: Bilateral nodes

tongue, skin, or <6 cm or contralateral
cervical soft tissue node(s)

N3: Node(s) >6 cm

d. Staging (see Table 2.4)

i. TNM group staging
– Stage I
• T1, N0, M0
– Stage II
• T2, N0, M0
– Stage III
• T3, N0, M0
• T1, N1, M0
• T2, N1, M0
• T3, N1, M0
– Stage IV
• T4, N0, M0
• T1, N2, M0
• T2, N2, M0
• T3, N2, M0
• Any T, N3, M0
• Any T, any N, M1
ii. Treatment modalities depending on stage
– Early stage (I–II): surgery +/– radiotherapy
– Locoregionally advanced (stages III–IVb): surgery, radio-
therapy, chemotherapy
• Metastatic: chemotherapy
iii. Surgical therapy
– Option nomenclature
• Radical neck dissection (RND): removes nodes from lev-
els I to V, SCM, CN 11, and internal jugular vein

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• Modified radical neck dissection (MRND): removal of all

lymph node levels routinely removed in an RND, but with
preservation of one or more of nonlymphatic structures
• Selective neck dissection (SND): each variation is
depicted by “SND” and use of parentheses to denote the
levels removed
• Extended radical neck dissection (ERND): refers to
removal of one or more additional lymph node groups or
nonlymphatic structures (e.g., skin, scalene muscle, etc.)
or both, not encompassed by the RND
iv. Local recurrence and surgical margins
– Despite appropriate initial treatment, oral squamous cell
carcinoma (SCCA) recurs in 25–48% of cases
– Histopathologic features
– 66–80% of patients with positive resection margin will
either develop a local recurrence or demonstrate persis-
tent disease on reoperation. Some investigators suggest
that adequate resxn in oral cancer should provide a margin
greater than 3 mm in width on permanent pathology section
(Nason RW, et al., Oral Surg, 2009;107(5):625–9)
v. Complications: chylous fistula, jugular vein thrombosis, carotid
artery injury, shoulder dysfunction; most significant morbidity
from RND is loss of CN XI
vi. Adjuvant therapy
– Radiotherapy
• General principles
○ Therapeutic radiation is delivered by two main meth-
ods: 1. Electromagnetic (photons): X-rays, gamma rays;
2. Particulate radiation: electrons, protons, neutrons
○ Depth of penetration required is the main criterion
used in choosing which energy to employ
○ Gray (Gy): dose absorbed by the tissue
■ 1 Gy = the absorption of 1 joule/kg
■ 1 Gy = 100 cGY = 100 rad
○ There is no absolute resistance to radiation; normal
tissue tolerance limits the dose
– Tissue effects
• Early: acute skin reactions, hyperemia, reduced salivary
gland function, mucositis, hypogeusia
• Late: chronic damage to skin, muscle, nerves, etc. Seem
not to occur when the tissues are exposed to less than
about 45 Gy
– Complications
• Osteoradionecrosis: an area greater than 1 cm of exposed
bone in a field of irradiation that had failed to show any
evidence of healing for at least 6 months
• Radiation carries: related to radiation-induced xerostomia

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3. Salivary gland tumors

a. Parotid gland
i. Parotid space (PS): paired lateral suprahyoid neck spaces
enclosed by the superficial layer of the deep cervical fas-
cia containing parotid glands, nodes, and extracranial CN7
branches
ii. Blood supply
– Arterial: branches from the external carotid
– Venous: retromandibular v., superficial temporal v.
iii. Lymphatics: lymph nodes: ~20 lymph nodes found in each
parotid gland
iv. Parotid duct (Stensen’s duct)
– Emerges from anterior PS, runs along surface of masseter
muscle, arches through buccal space to pierce buccinator
muscle at level of upper second molar
v. Benign (~2/3 of all parotid tumors)
– Mixed tumors/pleomorphic adenomas: most common tumor
in major and minor salivary glands
• Recurrent pleomorphic adenomas
– Warthin’s tumors (papillary cystadenoma lymphomatosum):
benign hamartomatous or reactive proliferation of ductal
salivary gland cells and lymphoid elements
– Oncocytoma: a very rare, benign salivary gland tumor
that may represent a reactive proliferation of activated
oncocytes
– Benign lymphoepithelial lesions
vi. Malignant (~1/3 of all parotid tumors)
– Mucoepidermoid carcinoma: most common malignant sali-
vary gland tumor; 70% found in the parotid gland, 15–20%
in the oral cavity, 6–10% in the submandibular gland
– Carcinoma ex pleomorphic adenoma: a malignant transfor-
mation of a benign pleomorphic adenoma
– Actinic cell carcinoma: uncommon, low-grade adenocarci-
nomas, of which 99% are found in superficial parotid lobe
– Polymorphous low-grade adenocarcinoma: arises from oral
minor salivary glands and does not occur as primary tumor
in any of the major salivary glands
– Adenoid cystic carcinoma
• Aggressive; 80% have perineural spread
– Epidermoid carcinoma
– Small cell carcinoma
– Lymphoma
– Salivary duct carcinoma

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vii. Diagnosis
– Clinical presentation: palpable mass, facial nerve impair-
ment, asymmetry of mouth, eye irritation, parapharyngeal
fullness, trismus, skin ulceration
– Rule of 80s for parotid masses
• 80% of tumors will be benign
• 80% will be in the superficial lobe
• 80% will be pleomorphic adenoma
– Key concepts or questions
• In mass lesions of PS area, is the mass intra- or extraparotid?
• What is the mass relationship to facial nerve?
• Designate mass as superficial, deep, or in the same plane
as intraparotid facial nerve
• Intraparotid CN7 estimated along line between stylomas-
toid foramen and lateral margin of retromandibular vein
• If malignancy in PS known or suspected, is there evidence
of perineural CN VII tumor?
○ Check fat in “bell” of stylomastoid foramen
○ If fat is obliterated, T1 C+ MR indicated
• Is the lesion single or multiple? Unilateral or bilateral?
○ Multiple bilateral lesions suggest unique differential
diagnosis
○ Consider Sjögren’s syndrome, benign lymphoepithelial
lesions associated with HIV, Warthin’s tumor, NHL,
acinic cell, or systemic metastases
○ If CN VII functions normally preoperatively, it generally
should be preserved
viii. Surgery
– Superficial parotidectomy: removal of the lateral portion
of the gland with preservation of the facial nerve; typical
operation for a parotid mass located superficial to the facial
nerve
– Superficial parotidectomy with partial deep lobe resection:
removal of the superficial gland and a portion of the gland
deep to the facial nerve
– Superficial parotidectomy with total deep lobe excision:
removal of the entire gland for tumors originating in the
deep lobe or for malignant neoplasms with suspected
metastasis to the parotid lymph nodes
ix. Complications
– Facial paralysis
– Frey’s syndrome (gustatory sweating): results when the
postganglionic parasympathetic nerve fibers of the parotid
gland aberrantly reinnervate the sweat glands of the skin.
Tx with Botox or insertion of Alloderm between skin and
deeper tissues

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b. Submandibular glands: ~50% of tumors are malignant

c. Sublingual glands: majority (>70%) of tumors involving the sublin-
gual glands are malignant
4. Lip tumors
a. Lower lip: most commonly involved lip, usually SCCA
b. Upper lip: less commonly involved, usually basal cell carcinoma
(BCCA)
5. Other
a. Ameloblastoma: benign but locally aggressive odontogenic tumor
i. Presents as swelling in tooth-bearing mandible or maxilla
ii. Three types
– Peripheral
• Odontogenic origin, similar to intraosseous ameloblasto-
mas but occur in soft tissue
• Tx with local excision
– Unicystic
• Tx with enucleation (peripheral ostectomy rarely necessary)
– Multicystic
• Locally aggressive
• Tx with segmental resection and reconstruction
b. Facial nerve palsy
i. Etiology
– Idiopathic (Bell’s palsy): most common
– Viral (e.g., varicella zoster virus/Ramsay Hunt syndrome)
– Traumatic
– Tumor
– Congenital (Möbius syndrome: paralysis of CN VI, VII; hemi-
facial microsomia, ~25% have CN VII dysfunction)
– Developmental
ii. Management
– Observation
– Surgical
• Decompression: if due to tumor or other compressive
etiology
• Primary repair (intracranial, intratemporal, extratempo-
ral): if recent and traumatic with severed ends in close
apposition
• Nerve grafting (grafting alone effective in first year;
afterwards, will also generally need to add target muscle
or provide static support)
○ Interpositional nerve graft (sural n. or great auricular n.)
• CN V as motor source is present and useful for treatment
of Möbius syndrome
○ Cross-face nerve graft (sural n.)
○ Hypoglossal-facial n. transfer
○ Hypoglossal-facial jump graft (sural n.)
○ Muscle or support source (for late reconstruction)

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• Free muscle flap (gracilis, latissimus dorsi, pectoralis

minor, serratus anterior) +/– cross-face n. graft
• Regional muscle transposition (temporalis, masseter,
digastric)
• Static facial support (browlift, blepharoplasty, upper lid
gold weight, lower lid support or repositioning, lip and
cheek support (fascia lata, GORE-TEX)

F. CONGENITAL
1. Embryology of the face
a. Face develops during weeks 3–8 of gestation
i. Frontonasal prominence: forms forehead and apex of nose
ii. Medial nasal prominences: forms primary palate, central maxilla
(premaxilla), nasal tip, columella, philtrum, central nose, septum
iii. Lateral nasal prominences: nasal ala
iv. Maxillary prominences: secondary palate, lateral maxilla, lat-
eral upper lip
vi. Mandibular prominences: mandible, lower lip, lower face
2. Etiology of craniofacial anomalies (theories of growth)
a. Fusion of processes (classic theory)
i. Facial prominences grow toward one another and fuse
ii. Failure of fusion results in facial clefts
b. Mesodermal penetration
i. Face consists of an ectodermal membrane with epithelial
seams demarcating the prominences
ii. Elevations and depressions in embryo occur with mesodermal
penetration between ectoderm and endoderm
iii. Failure of mesodermal penetration results in facial clefts
3. Craniofacial clefts
a. Tessier clefts
b. Oronasal clefts (Cleft no. 0–3)
i. Occur between the midline and Cupid’s bow, disrupting lip and
nose
– Cleft no. 0
• Directly in midline of lip and nose
• Can continue as cleft no. 14
– Cleft no. 1
• Through lateral margin of Cupid’s bow and into the nose
through parasagittal dorsum
• Subtype of nasal dysplasia
• Can continue as cleft no. 13

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– Cleft no. 2
• Through lateral margin of Cupid’s bow into middle third of
nostril
• Deficiency and flattening of nasal soft tissue
• Can continue as cleft no. 12
• Extremely rare
– Cleft no. 3
• Can be unilateral or bilateral
• Originates from lateral margin of Cupid’s bow across
base of nasal ala and extends through nasolacrimal duct
and into lacrimal groove
• Can continue as cleft no. 10 or 11
c. Oral-ocular clefts (cleft no. 4–6)
i. Occur lateral to Cupid’s bow, extending through soft tissues of
cheek and maxillary process
ii. Connect the oral and orbital cavities w/o disrupting the nose
– Cleft no. 4
• Anatomically disruptive cleft and complex
• Unilateral, bilateral, or combined with other clefts
• Starts lateral to Cupid’s bow between commissure of
mouth and philtral crest, extends lateral to nasal ala and
terminates in lower eyelid medial to the punctum
• May involve lower canaliculus
• Usually preserves medial canthus and lacrimal sac
– Cleft no. 5
• Lip is cleft medial to the commissure, extending into the
lateral third of the lower eyelid
• Rarest oro-ocular cleft
– Cleft no. 6
• Starts lateral to oral commissure and extends to lateral
third of lower eyelid
• Associated with coloboma (soft tissue deformity in the
lateral third of lower eyelid, lower eyelid notching)
• Hypoplastic lateral malar region
• Includes mild forms of Treacher Collins syndrome
d. Lateral facial cleft (cleft no. 7–9)
– Cleft no. 7
• Most common craniofacial cleft
• 10% bilateral
• May be due to stapedial artery occlusion during
embryogenesis
• Starts at lip commissure and extends toward the ear
• Variable degrees of bony and soft tissue deformities
• Mandible, maxilla, zygoma, and middle ear affected
• Associated with microtia
• Hemifacial microsomia (also known as Goldenhar/Oculo-
Auriculo-Vertebral Spectrum [OAV])

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– Cleft no. 8
• Isolated to lateral orbital region involving zygomatic fron-
tal suture
• Lateral canthal irregularity
• Associated with Goldenhar/OAV
• Extremely rare
– Cleft no. 9
• Involves superolateral orbit, dividing lateral third of
upper eyelid and brow
• Superior orbital rim and temporal bone involvement
• Associated with encephalocele
• Extremely rare
e. Treacher Collins syndrome
i. Bilateral cleft 6, 7, 8
ii. Autosomal dominant
iii. Soft tissue and skeletal hypoplasia
iv. Absence of zygomatic arch and lateral inferior orbital rim (max-
illary bone)
v. Hypoplastic mandibles
vi. Severe neonatal airway obstruction (most require tracheostomy)
4. Cranial clefts
a. Clefts involving the frontal bone above the orbit and skull base
b. Can be extensions of the midface clefts (cleft no. 10–14)
– Cleft no. 10
• Combined with cleft no. 4
• Central upper lid, brow, and orbit
• Coloboma present in upper lid
• Bony defect may include encephalocele
• May have hypertelorism
– Cleft no. 11
• Combined with cleft no. 3
• Medial eyebrow and upper lid deformity
• Bony defect through cranial base extending into ethmoid
sinuses
• Bony defect may include encephalocele
• May have hypertelorism
– Cleft no. 12
• Combined with cleft no. 2
• Disruption of medial eyebrow
• Bony defect of frontal bone extending down to nasofron-
tal buttress to pyriform rim
• Encephalocele and hypertelorism
– Cleft no. 13
• Extension of cleft no. 1
• Bony defect through olfactory groove and widened cribri-
form plate

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– Cleft no. 14
• Midline facial cleft and CNS abnormalities
• Combined with cleft no. 0
• Hypertelorism and cranium bifida may occur
• Frontonasal encephalocele
• May have cyclopia
• Holoprosencephaly: hypotelorism, microcephaly, and
severe CNS disturbance
• Poor neonatal life expectancy
5. Reconstruction of facial clefts (typically involves multiple stages over
many years)
a. Early soft tissue closure (within first year)
i. Removal of scar within cleft
ii. Layered closure of soft tissues including muscles
b. Delayed skeletal reconstruction
i. Variable age
ii. Dependent on severity of skeletal defect and growth
c. Goals of reconstruction
i. Correct macrostomia if present
ii. Eyelid reconstruction to protect globe
iii. Repair facial musculature
iv. Separate orbital, nasal, and oral spaces
v. Attempt aesthetic correction of deformity
vi. Consider external ear reconstruction if microtia exists
6. Cleft lip and palate
a. Cleft lip (CL)
i. Epidemiology
– Incidence
• Race
○ 2.1/1000 in Asians
○ 1/1000 in Caucasians
○ 0.41/1000 in blacks in North America
○ Isolated cleft palate (CP) relatively constant at 1/5000
among races
• Type
○ 46% cleft lip and palate (CLP); 33% isolated cleft
palate; 21% isolated cleft lip
• Location of cleft lip: 6 (left); 3 (right); 1 (bilateral)
• Gender
○ Males: cleft lip and palate most common (2:1 relative
to females)
○ Females: isolated cleft palate most common
ii. Etiology
– Multifactorial risk factors (genetic and environmental factors)
– 20–50% may be associated with a genetic contribution
(nonsyndromic clefts)
– Increased parental age (>30, esp. father)

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– Maternal folate and multivitamin (MVI) deficiency

– Teratogens: smoking, alcohol, anticonvulsants, retinoids,
steroids
– High altitude regions
iii. Associations
– Pierre Robin sequence: retrognathia; glossoptosis; respira-
tory distress; +/– cleft palate
– Syndromic clefts
• >300 syndromes include cleft lip and/or palate
• Stickler syndrome
○ 25% of syndromic CP
○ Autosomal dominant
○ Pierre Robin sequence, ocular malformations, hearing
loss
• Velocardiofacial syndrome (deletion long arm 22q)
○ 15% of syndromic CP
○ Autosomal dominant
○ Cleft palate, cardiac anomalies, abnormal facial fea-
tures, developmental delays
• Van der Woude syndrome
○ 19% of syndromic CP and CLP
○ AD
○ Cleft lip and palate and lower lip pits
iv. Embryology
– Cleft lip and CLP are distinct entities from isolated CP
– Cleft lip
• Primary palate (anterior to incisive foramen)
• Theories
○ Classical: failure of fusion of medial nasal process w/
maxillary process
○ Mesodermal penetration theory: epithelial breakdown
and separation—failure of reinforcement of facial
processes
– Cleft palate
• Secondary palate: hard palate posterior to the incisive
foramen
• Failure of fusion of the lateral palatal processes of the
maxillary prominence
• Palate normally fuses in anterior to posterior direction
v. Classification
– Cleft lip
• Unilateral versus bilateral
• Complete versus incomplete
○ Incomplete: varies in extent of deformity
○ Microform (forme fruste) most mild incomplete
• Vertical scar on skin
• Notch in vermillion border

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• Varying degree of vertical lip shortness

• Mild alar deformity
○ Complete: cleft extends through lip and nasal floor
○ Lateral maxillary segment position determines sever-
ity of cleft width as well and lip and nasal deformity
– Alveolar cleft
• Unilateral versus bilateral
• Complete versus incomplete
• Width of cleft determined by maxillary bony segment
position
– Palate
• Unilateral versus bilateral
○ Unilateral cleft palate: hard palate of noncleft side is
fused to the vomer, only one nasal airway open to mouth
○ Bilateral cleft palate: communication into both nasal
airways, no closure of hard palate to vomer exists
• Isolated soft palate cleft (hard palate intact to soft pal-
ate junction)
• Submucous cleft palate
○ Bifid uvula
○ Notching of posterior hard palate
○ Zona pellucida: thin central mucosal strip created by
diastasis of levator musculature in soft palate
○ Surgical repair only indicated if patient develops velo-
pharyngeal insufficiency (VPI)
vi. Cleft palate anatomy
– Vascular supply
• Hard palate
○ Greater palatine artery (from the maxillary artery),
passes through greater palatine foramen
• Soft palate
○ Lesser palatine artery (from maxillary artery)
○ Ascending pharyngeal artery (from external carotid
artery)
○ Ascending palatine branch of the facial artery
– Muscles
• Velopharyngeal closure is important for phonation, swal-
lowing, and breathing
• Levator veli palatine: elevates and pulls soft palate
posteriorly
• Tensor veli palatine: opens Eustachian tubes
• Superior pharyngeal constrictor: medial movement of the
lateral pharyngeal wall
• Palatopharyngeus: depresses soft palate
• Palatoglossus: depresses palate
• Uvularia: shortening of palate and upward movement

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• The soft palate muscles (levator) are laterally displaced

and abnormally inserted to hard plate posterior margin
• Goals of surgical repair are to release the aberrant
attachments of the levator musculature and repair trans-
versely across midline
viii. Management of the patient with cleft lip and/or palate
– Best managed through a multidisciplinary cleft surgery team
– Patient initially seen shortly after birth
– Initial focus is on feeding and weight gain
– CP patients benefit from special bottles/nipples (i.e.,
Haberman, Pigeon) and special feeding techniques
– Monitor patient closely for weight gain
ix. Presurgical orthopedics maneuvers (birth to primary lip surgery)
– Can be used dependent on orthodontic/dental support on
cleft team
• Nasoaveolar molding (NAM)
○ Passive process of molding
○ Decreases alveolar gap and aligns maxillary arch
○ Shapes the alar rim of the nose and lengthens columella
• Latham appliance
○ Active process
○ Pin retained appliance that is surgically inserted
○ Screw activation expands palate and retracts premaxilla
○ May be detrimental to maxillary growth
○ Not a commonly used technique
x. Lip adhesion (3 months of age)
– Partial preliminary closure of the cleft to decrease tension
• Helps align maxillary segments
• May be reasonable to perform in very wide cleft deformities
• Risk of dehiscence and poor scar formation for definitive
repair
• Not a commonly used technique
xi. Surgery
– Goals of treatment
• Cleft lip
○ Repair the orbicularis oris muscle sphincter across
upper lip
○ Close nasal floor
○ Shape alar rim and base to create nasal symmetry
○ Reconstruct the philtrum, Cupid’s bow, and tubercle.
Landmark rotation advancement flap first introduced
by Millard in 1954–55. Recommend: Stal S, et al., Plast
Reconstr Surg, 2009;123(4):1364–1377.
• Multiple modifications have been published, but no con-
sensus on best variants

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• Proper muscle repair takes tension off skin closure

• Add mucosal volume to tubercle to avoid whistle deformity
○ Provide normal lip symmetry, height, and minimize
scarring
• Cleft palate
○ Facilitate normal speech development
○ Facilitate normal hearing (hearing loss can be seen in
50% of patients with cleft palate)
○ Attributed to Eustachian tube dysfunction and recur-
rent otitis media
• Primary cleft lip and nasal repair (3–6 months of age)
○ Rotation advancement type flap (i.e., Millard, Mohler,
etc.) allow for most anatomic reconstruction of lip-
preserving lip subunits and reconstructing vertical
height of the upper lip
Stal S, et al., “Fifty years of the Millard rotation-advancement:
looking back and moving forward,” Plast Reconstr Surg,
2009 Apr;123(4):1364–77
○ Primary cleft nasal repair (integral part of the primary
lip surgery)
○ Release aberrant lateral nasal attachments to the pyri-
form rim
○ Shape alar rim and alar base to a more normal anatomy
○ Attempt domal unification through closed rhinoplasty
techniques
○ Avoid open rhinoplasty techniques to minimize scar-
ring and growth disturbance of the nose
○ Multiple primary cleft rhinoplasty techniques, but no
consensus on which is best
○ Primary cleft palate repair (10–12 months of age)
○ Single word speech develops in normal children as
early as 13 months age
○ Coordinated and integrated speech normally develops
by 2 years
○ Perform primary palate repair by 12 months prior to
speech development
○ Multiple primary palatoplasty techniques (e.g., Bardach
two-flap, von Langenbeck, V-Y pushback, Furlow
Z-plasty) touted w/o consensus
○ Key maneuvers for successful primary palate repair
• Multi layer closure
• Vomer flaps critical for nasal closure of hard palate
• Proper levator muscle release, transposition and repair
(i.e., intravelar veloplasty or Furlow Z-plasty technique)
• Tension-free oral lining closure
• Minor lip scar revisions (consider at 3–5 years of age)
○ Perform only if necessary based on severity of defor-
mity and effect on psychosocial development

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 Head and Neck 69
○ Try to improve scar appearance prior to entrance in
pre school/kindergarten (prior to peer interaction)
• Speech surgery for VPI: typically 4–8 years of age
○ Velopharyngeal incompetence (VPI)
• Incomplete closure of the nasopharyngeal airway during
speech
• Soft palate fails to reach posterior pharyngeal wall,
resulting in excessively nasal tone (hypernasality)
• ~20% of patients develop VPI after cleft palate surgery
• Etiology
○ May result postoperatively from shortened, scarred
soft palate
○ Inadequate initial muscle repair
○ May be due to congenital/developmental
○ Neurologic pharyngeal dysfunction (i.e., velocardiofa-
cial syndrome)
• Diagnosis
○ Clinical speech production (evaluation from trained
speech pathologist)
○ Videofluoroscopy or nasoendoscopy +/– measuring
pressure or nasal resonance (evaluate separate mus-
cular components of velopharyngeal function)
• Management
○ Nonoperative: speech therapy may be sufficient for
minor VPI
○ Operative
• No one best option for surgical treatment of VPI
• Evaluate for medialized carotid arteries in posterior
pharynx; may limit surgical options for treatment in that
patient population
• Associated with velocardiofacial syndrome, which is the
most commonly associated syndrome with CP
○ Surgical options
• Intravelar veloplasty to lengthen the soft palate associ-
ated with lowest risk of obstructive sleep apnea, strongly
consider particularly if original palate repair did not
include transverse orientation of levator veli palatini
• Furlow (double-opposing) palatoplasty: similar goals for
intravelar veloplasty, but transposes levator muscles as
opposing limbs of a Z-plasty. Some claim higher risk of
fistula due to resulting wound tension
• Sphincteroplasty pharyngoplasty: most appropriate if
poor medial excursion of lateral pharyngeal walls along
with short velum
• Pharyngeal flap: superiorly based musculomucosal flap
elevated from the posterior pharyngeal wall; most appro-
priate if poor velar motion with good lateral wall motion

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• Alveolar bone grafting (8–12 years of age)

○ Orthodontic palatal expansion typically required prior
to bone graft
○ Most successful when performed during transitional
dentition (8–12 years age) when canine root is incom-
pletely formed and permanent tooth migrating toward
the alveolar cleft
○ Iliac crest cancellous bone graft is optimal donor site
• Final lip scar revision (teenage years)
○ Indicated if results suboptimal and effect on psycho-
social development
○ Optimal results after cessation of facial growth
○ Common secondary deformities
• Malaligned vermillion border: Z-plasty often used for
correction
• Whistle deformity (deficient tubercle): various approaches
using Z-plasty and V-Y advancement flaps used depend-
ing on tissues missing
• Short lip/long lip
• Tight sulcus scar
• Orthognathic surgery (>16 years of age)
○ LeFort I maxillary advancement if maxillary arch retrusive
• Definitive cleft rhinoplasty (>16 years of age)
○ Multiple techniques described
○ Open rhinoplasty technique preferred to optimally cor-
rect tip deformities
○ Septoplasty and inferior turbinate procedure indicated
for airway obstruction
○ Cartilage grafting with septum for correction of tip
deformities
○ Consider floating rib cartilage graft as columellar strut
in patients with severe secondary cleft asymmetry and
very weak tip support
7. Craniosynostosis
a. Due to premature fusion of cranial suture
b. Cranial sutures are bone growth plates in the skull
c. Incidence is 1:2000 in general population
d. Majority of craniosynostosis cases are nonsyndromic
e. Virchow’s law: growth is inhibited perpendicular to affected suture,
and compensatory overgrowth of skull occurs parallel to affected
suture
f. Pathophysiology:
i. Multifactorial etiology (multiple associated genetic, physi-
ologic [metabolic, teratogenic, hematologic, etc.] and anatomic
factors identified)

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– Genetics
• 2% of nonsyndromic cases are hereditary
• 50% of syndromic cases are hereditary
• Multiple gene mutations identified (FGFR, TWIST, TGF-B,
MSX2, etc.)
ii. May cause increased intracranial pressure (ICP)
– Single suture involvement: up to 30% incidence increased
ICP
– Multiple sutures: 42% incidence increased ICP
– Potential sequelae of increased ICP
• Neurocognitive/psychomotor developmental delay
• Optic atrophy and vision changes/loss
• Gradual but irreversible process
• Difficult to predict which patients will develop increased
ICP and developmental delay
g. Diagnosis
i. Clinical exam: classic features of head shape
– Deformities are present at birth and will not autocorrect
ii. Verification with CT scan with 3D reconstructions (helpful for
educating parents and surgical planning)
h. Classification of single suture craniosynostosis
i. Sagittal
– 50% of all craniosynostosis cases (most common form)
– Results in scaphocephaly (dolichocephaly)
• Increased AP length
• Decreased bitemporal/biparietal/bioccipital width
– M:F ratio = 4:1
– Surgical correction (3–6 months of age)
• Goals: decrease AP dimension of skull and increase
transverse width of skull
• Options
○ Open approach: near total calvarial vault remodeling
for bitemporal, parietal, and occipital contouring (i.e.,
modified pi procedure with barrel stave osteotomies)
• Either via full coronal incision or limited incision
techniques
• Limited incision techniques benefit from postoperative
helmet molding for several months to optimize results
○ Endoscopic approach
• Must be combined with postoperative helmet molding for
several months to optimize results
ii. Coronal
– Unicoronal
• 20% of craniosynostosis
• Morphology: results in anterior synostotic plagiocephaly
○ Ipsilateral forehead flattening and superior orbital rim
retrusion

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○ Affected globe pulled up and lateral due to skeletal
dysmorphology of orbit
○ Ipsilateral harlequin deformity on coronal images of CT
face: obliquely oriented/diamond-shaped orbital mor-
phology due to malformation of the sphenoid wing
• Facial twist
○ Ipsilateral zygoma/maxilla pushed anteriorly
○ Nasal tip deviated to contralateral side
– Bicoronal
• 5% of craniosynostosis
• Morphology: results in turribrachycephaly
○ Tall forehead that is flat bilaterally
○ Short AP skull dimension
○ Bilateral harlequin deformity of orbits
• Surgical correction of coronal craniosynostosis (8–12
months age)
○ Bifrontal orbital advancement (multiple techniques
and modifications exist)
• Goals
○ Increase intracranial volume anteriorly
○ Bring supraorbital rims forward
○ Contour frontal bones to correct forehead deformity
iii. Metopic
– 10% of craniosynostosis
– Morphology: results in trigonocephaly (triangular-shaped
forehead)
– Bitemporal narrowing and constriction
– Medialization of orbits resulting in cross-eyed appearance
– Must differentiate from benign metopic ridge
• Prominent fused metopic ridge that occurs during normal
metopic suture fusion (between 3 and 18 months age)
• May result in visible and palpable metopic ridge that
appears well after birth
• No bitemporal narrowing
• Normal forehead contour
– Surgical correction of metopic craniosynostosis (8–12 months
of age)
• Bifrontal orbital advancement (multiple exist)
• Goals
○ Increase intracranial volume anteriorly
○ Bring supraorbital rims forward
○ Contour frontal bones to correct forehead deformity
iv. Lambdoid
– 3% of craniosynostosis (least common)
– Morphology: results in posterior synostotic plagiocephaly
• Ipsilateral mastoid bone bulge
• Lambdoid ridging

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• Posterior skull base tilt (inferior on affected side)

• Ipsilateral ear is pulled down from skull base dysmor-
phology (relatively posterior to contralateral ear)
• Contralateral parietal compensatory bulge
– Must differentiate from oblique occipital deformational
plagiocephaly
• Due to cranial molding from infant sleep position
• Deformity not present at birth
• Not associated with above physical findings, but rather
with deformation primarily in occiput and anterior posi-
tion of ipsilateral ear
• Treatment of deformational plagiocephaly with molding
helmet therapy (nonsurgical)
– Surgical correction of lambdoid craniosynostosis (3–6 months
of age)
• Occipital and parietal craniotomy and contouring (i.e.,
switch cranioplasty)
• Multiple techniques and modifications exist
• Goals
○ Increase posterior vault intracranial volume
○ Correct compensatory parietal bulging
○ Correct occipital skull deformity
i. Syndromic craniosynostosis
i. Crouzon syndrome
• Autosomal dominant
• Usually present with coronal +/– lambdoid synostosis
• Exorbitism/proptosis
• Midface hypoplasia
• Normal extremities
• Intracranial issues: hydrocephalus, increased ICP, mild
mental impairment
– Apert syndrome
• Autosomal dominant
• Usually bicoronal synostosis
• Proptosis and hypertelorism
• Midface hypoplasia
• Syndactyly of hands and feet
• Intracranial issues: increased ICP, significant mental
impairment common
– Saethre-Chotzen syndrome
• Autosomal dominant
• TWIST gene mutation
• Usually bicoronal craniosynostosis
• Normal mental status
• Low anterior hairline of forehead

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• Ptosis of upper eyelids

• Midface hypoplasia
• Partial syndactyly of fingers (i.e., minor webbing)
– Pfeiffer’s syndrome
• Autosomal dominant
• Usually bicoronal synostosis (occasional sagittal synostosis)
• Exorbitism and hypertelorism
• Usually normal mental status
• Broad thumbs and toes
– Carpenter’s syndrome
• Autosomal recessive, gene 6P11
• Mental impairment
• Variable suture involvement
• Displaced medial canthi
• Low-set ears
• Brachydactyly
• Syndactyly of fingers and toes
• Cardiac anomalies present (e.g., ASD/VSD)
• Possible venous and bony abnormalities
j. Commonly asked about syndromes and sequences
i. Useful website is “Online Mendelian Inheritance in Man”
(OMIM) at [Link]/sites/entrez?db=OMIM
– Can search by name of syndrome or by features present in
patient
ii. Binder syndrome (maxillonasal dysplasia)
– Maxillonasal dysplasia with short nose and flat bridge,
short columella, acute nasolabial angle, convex upper lip,
+/– angle III malocclusion
iii. Goldenhar syndrome (OAV dysplasia)
– Hemifacial microsomia + epibulbar dermoids and vertebral
anomalies
– Upper lid coloboma
iv. Hemifacial microsomia (median facial cleft syndrome)
– Second most common congenital facial anomaly
– 80% unilateral
– Anomalies in all three germ lines of first and second bran-
chial arches (incl. CN VII)
• Microtia, mandibular ramus hypoplasia common. May
have macrostomia, facial paralysis, and hypoplasia of
muscles of mastication
– Hypertelorism, broad nasal root, lack of a nasal tip, widow’s
peak, anterior cranium bifidum occultum also seen
– Most often sporadic

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v. Kabuki syndrome
– Congenital mental retardation with additional features
such as
• Postnatal dwarfism, long palpebral fissures with eversion
of lower third of lower eyelid (hence Kabuki, a reference
to a form of traditional Japanese theater), large prominent
earlobes, cleft or high-arched palate, scoliosis, short fifth
finger, infantile otitis media, and radiographic anomalies
of hands, hips, a/o vertebrae
vi. Möbius syndrome
– Bilateral palsy of CN VI (abducens) and VII (facial)
– Other CN (III, V, IX, XI, XII) very rarely involved
– Up to ¼ of patients also have limb anomalies (syndactyly,
clubfeet, etc.)
vii. Nager syndrome (acrofacial dysostosis)
– Treacher Collins-type dysostosis + absent radius, radioul-
nar synostosis, and thumb hypoplasia/aplasia
viii. Pierre Robin sequence
– Triad of microretrognathia, glossoptosis, and upper airway
obstruction
– Often associated with Tessier no. 7 cleft (macrostomia)
– Thought to result from tongue abnormally interposing between
palatal shelves in utero
– Options to manage airway obstruction include (in order
of severity): positioning, lip-tongue adhesion, distraction
osteogenesis, a/o tracheostomy
– Patients often have feeding difficulties, and may require
tube feeding
ix. Romberg disease (progressive hemifacial atrophy)
– 95% unilateral; may affect any or all tissues in face (bone,
cartilage, skin, fat, etc.)
– Typically begins in first 2 decades of life, usually stabilizing
after several years
– Injectable fillers or grafts may help with mild cases whereas
advanced cases benefit from free flap reconstruction
x. Treacher Collins syndrome (mandibulofacial dysostosis)
– Gene 5q32-q33.1, autosomal dominant
– Combination of Tessier cleft no. 6, 7, and 8
– Features antimongoloid eye slant, lower lid coloboma, micro-
gnathia, microtia, zygomatic arch hypoplasia, macrostomia
– Often includes cleft palate a/o conductive hearing loss
xi. Van der Woude syndrome (lip-pit syndrome)
– Gene 1q32–q41
– Autosomal dominant
– Most common cleft syndrome
– Lower lip pits a/o sinuses, and cleft lip a/o cleft palate

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xii. Velocardiofacial syndrome

– Most common syndrome associated with cleft lip and palate
– May include velopharyngeal insufficiency, facial and car-
diac anomalies, and absent thymus/parathyroid glands
8. Microtia
a. External ear development occurs from the first (mandibular) and
second (hyoid) branchial arches
b. Failure of branchial arch development causes microtia
c. Theories
i. Teratogens (i.e., thalidomide, retinoids, Accutane)
ii. Ischemia
d. Second most common facial congenital deformity
e. Associated with hemifacial microsomia/OAV spectrum, other
genetic syndromes
f. 80% unilateral (right:left:bilateral, 5:3:1)
g. Associated hearing defects
i. Middle ear and external auditory canal (EAC) defects may be
present
ii. Hearing defects are 80–90% conductive, 10–20% sensorineural
iii. Causes of hearing defects
– Ossicular chain disruption
– Absence of ossicles
– Atresia of EAC
iv. Hearing issues managed by otolaryngologists (may benefit
from early placement of bone-anchored hearing aids)
h. Classification
i. Grade I: less than complete development of the external ear with
identifiable structures and a small but present external ear canal
ii. Grade II: partially developed ear (usually the cephalad portion
is underdeveloped) with a closed stenotic external ear canal
producing a conductive hearing loss
iii. Grade III: absence of the external ear with a small peanut-
like vestigial structure with absence of the EAC and eardrum.
Grade III microtia is the most common form of microtia
iv. Grade IV: absence of the total ear or anotia
i. Surgical reconstruction
i. Timing
– 6+ years of age (some surgeons advocate >10 years of age)
– Attempt to match unaffected side (about 90% fully grown
by 6 years of age)
– Child needs to be ready psychologically for multistaged,
complex reconstructive surgery
– Need adequate growth of donor tissue (i.e., rib cartilage) if
considering autologous reconstruction
– EAC reconstruction usually performed after external ear
reconstruction

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ii. Goals
– Creation of a normal appearing external ear (very difficult to
achieve)
iii. Options
– Autologous costal cartilage grafting
• Modification from original techniques popularized by
Brent and Nagata. Recommend: Bauer BS, Plast Reconstr
Surg, 2009;124(1Supp):143–26e
• Create a subcutaneous pocket and rib cartilage
framework
• Involves multiple staged procedures
• Steep learning curve with autologous reconstruction
– Porous polyethylene (Medpor) implant
• Requires temporoparietal fascia flap for implant cover-
age with skin grafting
– Osseointegrated implant with custom prosthetic
• Requires experienced prosthetist to fabricate ear
9. Facial masses
a. Midline: image with CT before invasive procedures
i. Embryology: the fonticulus frontalis is transiently open between
the frontal and nasal bones. Additionally, a space between
the nasal bones and nasal cartilage (which later becomes the
foramen cecum) is briefly open as well. Failure of closure of either
of these spaces can lead to sinus tract a/o dermoid formation
ii. Dermoid cyst: most common, contains sebaceous material,
may communicate with intracranial space
iii. Encephalocele: herniation of brain through skull defect (from
one of the two spaces above), covered by dura and communicat-
ing with CSF
iv. Glioma: glial neural tissue, not covered by dura
10. Prominent ears
a. Pathoanatomy: one or more of the following
i. Antihelical fold relatively undeveloped
ii. Concha prominent
iii. Earlobe protruding
b. Surgery
i. Usually delayed until at least 4 years of age
ii. Techniques for components
– Antihelical fold: conchoscaphal (Mustardé) sutures, ante-
rior (Stenstrom) abrasion, parallel incisions along antihelix
(Converse–Wood-Smith)
– Conchal prominence: conchoids sutures to mastoid fascia
(Furnas), partial/crescent conchal excision

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11. Orthognathic surgery

a. General
i. Definitions
– Relative position
• Buccal: toward or apposed to the cheek side of the tongue
(oft. opposite to lingual)
• Distal: away from the midline or sagittal plane of the den-
tal arch (opposite of mesial)
• Labial: toward or apposed to the lip side of the tooth (oft.
opposite of lingual)
• Lingual: toward or apposed to the tongue side of the tooth
(oft. opposite of labial or buccal)
• Mesial: toward the midline or sagittal plane of the dental
arch (opposite of distal)
– Orthognathic points and angles
-A: point of innermost curvature from maxillary anterior
nasal spine to the alveolar process
-B: point of innermost curvature from the chin to the alveo-
lar process
• Nasion (N): junction of nasal and frontal bones at the
most posterior point of the curve of the nose
• Sella (S): center of the hypophyseal fossa
• Porion: upper margin of external auditory canal
• Pogonion (Pg): most anterior chin point
• SNA: establishes the maxillary position in relation to skull
base (normal = 81.2)
• SNB: establishes mandibular relationship to skull base
(normal = 77.3)
• SNPg: represents degree of chin prominence relative to
the SNB (mandible position; normal = 80)
– Other
• Overbite: vertical
• Overjet: horizontal
• Proclination: anterior angulation of anterior teeth
• Retroclination: posterior angulation of anterior teeth
b. Angle classification
i. Class I (normal): mesiobuccal cusp of maxillary first molar lies
in buccal groove of mandibular first molar
ii. Class II (retrognathic): mesiobuccal cusp of maxillary first
molar lies mesial to buccal groove of mandibular first molar
iii. Class III (prognathic): mesiobuccal cusp of maxillary first molar
lies distal to buccal groove of mandibular first molar
– Tx options
• LeFort I advancement of maxilla (if nose, orbital rim, and
malar prominences in good position)
○ Immediate
○ Distraction osteogenesis

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 Head and Neck 79

• Mandibular setback: risks include posterior placement of

tongue (airway compromise)
c. Other conditions
i. Transverse maxillary deficiency
– Tx w/ subtotal LeFort I osteotomy (nasal septum, midline
palate, bilateral pterygoid plates, bilateral anterior and lat-
eral antral walls; notlateral nasal walls, though) to achieve
maxillary expansion
– Vertical maxillary excess (long-face syndrome)
• Narrow alar base, obtuse nasolabial angle, and anterior
open bite
• Increased mentalis muscle strain and labial incompe-
tence along with excess gingival show and exposure of
upper incisors
• Tx w/ LeFort I osteotomy with maxillary impaction +/–
osseous genioplasty
d. Procedures
i. Maxillary osteotomies: may be traditional or combined with
distraction osteogenesis (DO); the latter is indicated in previ-
ously operated or scarred tissue
– LeFort I
• Tx of choice (combined with DO) for maxillary retrusion
associated with cleft lip and palate
• Bleeding from descending palatine artery not uncommon,
may be divided with impunity
– LeFort II, III less commonly indicated
ii. Mandibular osteotomies
– Bilateral sagittal split osteotomy
• Lower lip paresthesia (bilateral) from inferior alveolar
nerve neurapraxia is most common postop complication
○ >85% incidence immediate postop, <15% at 1 year
(more prolonged in elderly patients)

G. AESTHETICS
1. Evaluate
a. As a whole and in thirds
i. Forehead, midface, and lower jaw and neck
2. Rhinoplasty
a. Nasal anatomy
i. Aesthetic subunits: four basic components: bony vault (upper third);
vault (middle third); nasal tip/base (lower third); nasal septum
– Also assess chin (nose, lip, chin in relation to Riedel plane);
to create balance, a chin implant, genioplasty, or orthogna-
thic surgery may be beneficial
– Nasolabial angle: 90–105° (males), 100–120° (females)

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b. Male rhinoplasty. Recommend Rohrich RJ, et al., Plast Reconstr

Surg, 2003;112(4):1071–85
i. Red flag: SIMON (single, immature, male, overly expectant,
narcissistic). Males typically have no supratip beak, as well as
broader, thicker skin.
c. Aging rhinoplasty (Rohrich, et al., PRS)
i. Main problem is drooping tip that can give illusion of dorsal
hump. Fix tip first by suturing (interdomal, transdomal, inter-
crural, etc.) a/o tip graft.
d. Operative
i. Open: infracartilaginous incision combined with columellar inci-
sion with stairstep, transverse, or gull wing incision
ii. Closed: must have adequate tip projection, good dorsum, good
midvault
iii. Grafts: columellar strut graft (support nasal tip projection; tip
grafts for nasal lobule [“shield,” “Peck” grafts]; alar batton grafts
[prevent alar collapse]; spreader grafts [increase internal nasal
valve angle])
3. Rhytidectomy
a. May consider in multiple planes: subperiosteal, deep plane/SMAS
elevation, lateral SMASectomy, MACS lift (i.e., SMAS plication)
b. Preoperative
i. HTN: main risk factor for hematoma; consider use of clonidine
ii. Tobacco use: contraindication, higher risk of skin slough, consider
iii. Cranial nerve exam
c. Intraop
i. Incisions
– Temporal: either at hairline or within hairline; assess lateral
orbital rim to hairline width (if 3 cm or more, consider hair-
line incision)
– Ear: at ear facial border anterior and posteriorly with pre- or
retrotragal approach
– Posterior neck: hairline or stair-step incision
ii. Midface rhytidectomy (malar fat pad)
– Intraoperative: temporal incision, dissect down to deep tem-
poral fascia
• Release orbital retaining ligaments and zygomatic
retaining ligaments via subperiosteal route
iii. Neck: assess for excess fat, skin, and/or platysmal banding
– Address through submental incision and posterior neck incision;
avoid greater auricular nerve and marginal mandibular nerve
– Intraoperative: involves lateral platysmaplasty and midline
plastysmal plication with submental liposuction

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4. Blepharoplasty
a. Upper blepharoplasty
i. Anatomy
– Outer lamella
• Skin 0.5–0.7-mm thick (thinnest in the body)
– Middle lamella
• Levator palpebrae: innervated by CN III
• Müller’s muscle: innervated by sympathetics
– Inner lamella
• Conjunctiva
• Fat found in medial and lateral components. Medial fat
paler.
ii. Evaluation
– With what is the patient unsatisfied?
– Medical history: renal, cardiac, thyroid dz, sx of myasthenia
gravis
• Blepharochalasis: recurrent bouts of upper lid edema—
contraindication to surgical intervention
• Dermatochalasis: excess skin in the upper lid
– Hooding
– Scleral show: no scleral show should be seen below the infe-
rior limbus pre- or postoperatively—sign of ectropion
– Brow position:
• Male: flatter brow with position at superior orbital rim;
• Female: 1 cm above the orbital rim, arch should be pres-
ent with peak between lateral corneal limbus and lateral
commissure
– Schirmer’s test: test to assess adequate eye tear production
(normal is greater than 15 mm on filter paper)
– Assess levator function and assess for preoperative ptosis:
upper lid should only cover 1–2 mm of upper limbus
iii. Visual acuity and visual fields
iv. Surgery
– Marking: in upright position; calipers for precise measure-
ments; lower border corresponds with upper margin of
tarsus (usu. 8–10 mm above ciliary margin); upper border
determined by pinch
– Anesthetic: local versus sedation
– Technique: usu. excise skin with strip of orbicularis, skin and
medial and middle fat compartments ; bulging laterally indi-
cates lacrimal gland ptosis (suspend, don’t resect gland)
– Postoperative: ocular pain could indicate retrobulbar
hematoma and should be addressed immediately (ste-
roids, acetazolamide, removal of sutures, decompression of
hematoma, elevation)

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b. Lower
i. Evaluation (primary focus: avoid postoperative ectropion)
– Lid laxity: Snap test
– Vector: negative or positive vector based on relative position
of globe to malar prominence
– Distance from bony rim to palpebral commissure
– Sitting v. recumbent
– 3 fat compartments: medial, middle, and lateral
ii. Principles
– Resect redundant skin, usually fat, never muscle, orbicular
resuspension, orbital fat grafting or repositioning to blend
lid-cheek junction
– Approaches: skin-muscle technique; skin only externally
with transconjunctival fat approach (preserves middle
lamella)
5. Brow lift
a. Position:
i. Male: flatter brow with position @ superior orbital rim
ii. Female: 1 cm above the orbital rim; arch should be present with
peak between lateral corneal limbus and lateral commissure
b. Approaches:
i. Coronal
ii. Hairline
– Behind hairline: avoid in patients w/ long vertical height
forehead
– Endoscopic: difficult in high arching foreheads; addresses
corrugator, procerus muscles
– Direct brow lift: very powerful, but reserve for persons with
male pattern baldness in whom scar cannot be concealed
in hairline

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 3 ■ HAND AND PERIPHERAL NERVE

A. ANATOMY
1. Osteology
a. Carpus: eight carpal bones aligned in two rows along Gilula’s lines
i. Proximal row (radial to ulnar), forms radiocarpal and ulnocarpal
joints, convex/concave
– Scaphoid
– Lunate
– Triquetrum
– Pisiform
• Situated palmar to the above three; pisotriquetral joint is
separated from adjacent articulations
• The hamate contributes to ulnar boundary of the carpal
tunnel; the pisiform forms the ulnar border of Guyon’s canal
ii. Distal row (radial to ulnar), forms midcarpal joint (normally
does not communicate the radiocarpal joint), and also articu-
lates with five metacarpals, relatively straight
– Trapezium
• Articulates with thumb metacarpal at the carpometacar-
pal joint (a saddle joint)
• The trapezial ridge along with the scaphoid tuberosity
form the radial boundary of the carpal tunnel
– Trapezoid: the trapeziotrapezoid joint can be involved with
pantrapezial arthritis and deserves inspection during thumb
carpometacarpal (CMC) arthroplasty
– Capitate
– Hamate: there is more motion at the ring/small finger CMC
joints that facilitates power grip on the ulnar aspect of the
hand
b. Metacarpals
i. “Stable portion” of hand formed by second and third metacar-
pals which act as single osseoligamentous unit
ii. Mobile portion of hand formed by fourth and fifth metacarpals
which also are responsible for “power grip”
c. Phalanges
d. Joints
i. Radiocarpal
ii. Distal radioulnar joint (DRUJ)
iii. Intercarpal and midcarpal
iv. Carpometacarpal
v. Metacarpophalangeal (MCPJ)

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vi. Interphalangeal joint (IPJ): hinge joints (ginglymus), rotate

only in sagittal plane, excellent resistance to angular stress.
Stability provided by box-like arrangement with floor = volar
plate, two sides = proper collateral ligament (dorsal) + acces-
sory collateral ligament (volar); the “critical corner” defines the
insertion of the collaterals at the volar plate
– proximal interphalangeal (PIP): able to flex to 105°
– distal interphalangeal (DIP): able to flex to 80° (smaller ROM
than PIP)
2. Surface landmarks
a. Lister’s tubercle: in line between index and middle fingers, 0.5 cm
proximal to radiocarpal joint. Extensor pollicis longus (EPL) tendon
passes along ulnar side, extensor carpi radialis brevis (ECRB) goes
to the radial side of it. Useful landmark for wrist aspiration and
arthroscopy: 1 cm distal to Lister’s tubercle is the sulcus delineat-
ing the radiocarpal joint and the interval between the third and
fourth extensor compartments
b. Radial styloid: intimately associated with the first dorsal compart-
ment containing the abductor pollicis longus (APL; often multiple
slips) and extensor pollicis brevis (EPB)
c. Distal wrist flexion crease: on radial aspect, corresponds to distal
pole of the scaphoid; useful for percutaneous screw fixation of non-
displaced scaphoid waist fractures utilizing a retrograde technique
d. Distal palmar crease: roughly corresponds with proximal extent of
A1 pulley
e. Pisiform: attachment for flexor carpi ulnaris (FCU)
f. Hamate hook: palpable 1 cm radial and distal to pisiform
g. Scaphoid tubercle: palpable on radial aspect of hand base just dis-
tal to distal wrist flexion crease, particularly noticeable when wrist
radially deviated
h. Anatomic snuff box: defined by volar radial first extensor compart-
ment and dorsoradial third extensor compartment
3. Vascular supply
a. Brachial artery
i. Begins from axillary artery after lower border of teres major
ii. Gives off profunda brachii fairly proximal
iii. May divide into two parallel vessels
iv. Approach via bicipital groove
b. Radial artery: approach via dividing bicipital aponeurosis in ante-
cubital fossa. Brachial artery bifurcation is ulnar to biceps tendon.
The radial artery then lies between brachioradialis and flexor digi-
torum superficialis (FDS) in forearm, and runs with the superficial
radial nerve (SRN) under the brachioradialis (BR) muscle belly. In
the midforearm, it lies superficial between the BR and flexor carpi
radialis (FCR) and passes radial to FCR. At the wrist, it divides into
the superficial and deep branches to contribute to the superficial
palmar arch and form the deep palmar arch respectively. The deep

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 Hand and Peripheral Nerve 85

radial artery courses deep to the first extensor compartment ten-

dons at the level of the wrist and lies on the dorsal capsule of the
scaphotrapezial joint within the snuff box and then runs around the
base of first metacarpal before giving off princeps pollicis artery,
radial digital artery of two index fingers, and supplying superficial
arch (21.5% of persons with poor collaterals or incomplete arch)
c. Ulnar artery: after dividing from brachial artery, passes between FCU
and flexor digitorum profundus (FDP), just radial to ulnar nerve and
FCU at wrist. Travels through Guyon’s canal with ulnar nerve, then
supplies superficial palmar arch
i. Hypothenar hammer syndrome: thrombosis of ulnar artery
and proximal superficial palmar arch, generally from repeated
direct trauma (smoking appears to increase the risk as well)
– Dx: presents with pain, cold sensitivity, and paresthesias in
ulnar distribution
– Tx: resect involved segment of ulnar artery and reconstruct
with vein
4. Nerves
a. Brachial plexus overview
i. Normally receives contributions from C5 to T1 nerve roots
– Prefixed (62% of population) refers to contribution from C 4;
postfixed refers to contribution from T 2
ii. Components: (roots, trunks, divisions, cords, branches “Rob
Taylor drinks cold beer”)
– Roots: C5–T1 usually contribute (C4 contribution = “prefixed”;
C5 contribution = “postfixed”)
– Trunks (3)
• Upper trunk from C5, C6
• Middle trunk from C7
• Lower trunk from C8, T1
– Divisions (Six: each trunk divides into anterior and posterior
divisions for a total of three anterior, three posterior divisions)
– Cords (three)
• Lateral: most cephalad/superior, formed from anterior
divisions of upper and middle trunks; gives off muscu-
locutaneous nerve and contributes (along with medial
cord) to median nerve
• Posterior: between and posterior lateral and medial
cords, formed from posterior divisions of all three trunks;
gives off radial, axillary, and thoracodorsal nerves
• Medial: most caudad/inferior, formed from anterior divi-
sion of lower trunk, gives off ulnar nerve and contributes
(along with lateral cord) to median nerve
– Peripheral nerves
• Musculocutaneous: from lateral cord
• Median: from lateral and medial cords
• Radial: from posterior cord

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 86 Hand and Peripheral Nerve

• Axillary: from posterior cord

• Thoracodorsal: from posterior cord
• Ulnar: from medial cord (roots C7–T1)
b. Peripheral nerves
i. Musculocutaneous nerve
– Innervates coracobrachialis, brachialis, and biceps from
lateral cord
– Purely sensory end branch: lateral antebrachial cutaneous
nerve (LABCN)
• Medial brachial nerve
• Medial antebrachial nerve: can be used as nerve grafts
for peripheral nerve reconstruction in lieu of sural nerve;
needs to be isolated and protected during ulnar nerve
decompression at the elbow; usually crosses 3.5 cm dis-
tal to medial epicondyle
ii. Median nerve
– From lateral and medial cords
– Branches
• Anterior interosseous (purely motor to flexor muscles in
forearm)
• Main (mixed sensory and motor to hand)
iii. Radial nerve
– From posterior cord
– In distal arm lies between BR and brachialis. Bifurcation
into SRN and motor/Posterior interosseous nerve (PIN) at
level of radiocapitellar joint, passes between supinator
heads to enter extensor compartment of forearm
– Branches
• Posterior interosseous nerve: sensory branch to wrist
capsule (good donor for digital nerve grafts) and motor to
EDC, EDM, APL, EPB, EPL, EIP, and ECU. At level of wrist,
lies on floor of fourth extensor compartment with PIA
• Superficial sensory nerve: sensory to dorsum of thumb,
first web space, IF, MF, and radial RF to level of PIP joint. In
volar midforearm, deep to BR with radial artery. 8 cm prox-
imal to radial styloid, exits into dorsal forearm between BR
and ECRL. Use of spanning wrist external fixation requires
identification of RSN at this interval; ex fix pins are then
placed in the ECRL/ECRB interval (one interval dorsal)
iv. Axillary nerve: from posterior cord, passes through quadrilat-
eral space, provides motor and sensation to deltoid region
v. Thoracodorsal nerve: from posterior cord, innervates latissi-
mus dorsi
vi. Ulnar nerve
– From medial cord (roots C7–T1)
– Motor supply to FCU and majority of intrinsic hand muscles,
travels in forearm and wrist immediately radial to ulnar artery

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vii. Digital nerves

– Common digital nerves bifurcate in the palm into proper
digital nerves to second third and fourth web spaces. The
index and small finger have independent radial and ulnar
digital nerves respectively. The radial and ulnar digital
nerves to the thumb are branches off the lateral division of
the median, never in the carpal tunnel. In the palm, digital
nerves are dorsal to their corresponding digital arteries, but
in the fingers, digital nerves are volar to the arteries
5. Muscles: see chart below

Joint/Motion Muscle Origin/Insertion Nerve Root

Elbow
Flexion Brachialis Anterior humerus/ MC C5, C6, C7
anterior ulna
Biceps Scapula & prox humerus/ MC C5, C6
radial tuberosity
Extension Triceps Scapula / olecranon Radial C6, C7, C8
Forearm
Supin Biceps Coracoid process & MC C5, C6
supraglenoid tubercle/
radial tuberosity
Supinator Lateral epicondyle + Radial C7, C8
ulna/lateral proximal
radius
Pron Pronator teres Medial epicondyle + Median C6, C7
coronoid process/
Pronator quadratus radius AIN C7, C8
Wrist
Flexion Flexor carpi radialis Medial Epicondyle/base Median C6, C7
2nd & 3rd metacarpa
Flexor carpi ulnaris Medial epicondyle/ Ulnar C7, C8, T1
pisiform
Extension Extensor carpi radialis Lateral supracondylar Radial C6, C7
longus ridge/base 2nd
metacarpal
Extensor carpi radialis Lateral epicondyle/base Radial C7, C8
brevis 3rd metacarpal

Extensor carpi ulnaris Lateral epicondyle/base Radial C7, C8

5th metacarpal
(continues)

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 88 Hand and Peripheral Nerve
(continued)
Joint/Motion Muscle Origin/Insertion Nerve Root
Finger (MCP)
Flexion Medial two lumbricals Radial FDP/MCPJ Ulnar C8, T1
extensor expansion
Lateral two lumbricals Radial FDP/MCPJ Median C8, T1
extensor expansion
Extension Extensor digitorum Lateral epicondyle/ PIN C7, C8
communis splits into slips distal
to wrist
Extensor indicis Distal dorsal ulna/blends PIN C7, C8
with EDC at MCPJ
Extensor digiti minimi Lateral epicondyle/ PIN C7, C8
blends with EDC
at MCPJ
Abd Dorsal interossei* Radial (or ulnar) Ulnar C8, T1
metacarpal/radial (or
ulnar) base of P2 and
extensor expansion
Abductor digiti minimi Pisiform/P1 Ulnar C8, T1
Add Palmar interossei* Metacarpal/P1 Ulnar C8, T1
Finger (PIP)
Flexion Flexor digitorum medial epicondyle/P2 Median C8, T1
superficialis
Extension Extensor digitorum Lateral epicondyle/ PIN C7, C8
communis central slip P2
Extensor indicis Lateral epicondyle/ PIN C7, C8
central slip P2
Extensor digiti minimi Lateral epicondyle/ PIN C7, C8
central slip P2
Finger (DIP)
Flexion Flexor digitorum Medial epicondyle/P3 Ulnar; C8, T1
profundus AIN
Extension Extensor digitorum Lat epicondyle/terminal PIN C7, C8
communis slip P3
Extensor indicis Lat epicondyle/terminal PIN C7, C8
slip P3
Extensor digiti minimi Lateral epicondyle/ PIN C7, C8
terminal slip P3
(continues)

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 Hand and Peripheral Nerve 89
(continued)
Joint/Motion Muscle Origin/Insertion Nerve Root
Thumb
Palmar Abductor pollicis Ulna + radius + IO/1st Radial C7, C8
abduction longus metacarpal
Abductor pollicis Scaphoid + trapezium/ Median C8, T1
brevis radial thumb P1
Dorsal Adductor pollicis 2nd and 3rd Ulnar C8, T1
abduction metacarpals/thumb P1
Thumb MCP
Flexion Flexor pollicis brevis 1st metacarpal/ulnar P1 Ulnar C8, T1
(FPB; deep head) Trapezium/thumb
FPB (superficial head) sesamoid Median C8, T1
Extension Extensor pollicis Radius + IO/thumb P1 Radial C7, C8
brevis
Thumb IP
Flexion Flexor pollicis longus Radius + IOM/thumb P2 Median C7, C8
Extension Extensor pollicis Ulna + IOM/thumb P2 Radial C7, C8
longus

* Interossei also flex MCP and extend PIP and DIP.

MC = musculocutaneous nerve (from lateral cord)
PIN = posterior interosseous nerve (branch of radial)
AIN = anterior interosseous nerve (branch of median)
MCP = metacarpophalangeal
PIP = proximal interphalangeal
DIP= distal interphalangeal
IP= interphalangeal
Source: Adapted from JR Doyle, Orthopaedic Surgery Essentials: Hand & Wrist, Lippincott Williams & Wilkins,
Philadelphia; 2005, p. 12

6. Ligaments
a. Collateral ligaments
i. Metacarpophalangeal joint (MCPJ)
– Quadrangular, symmetrical; cam shape of metacarpal head
keeps them taut in flexion, lax in extension
– MCPJ should be immobilized in flexion to avoid stiffness
ii. Interphalangeal joints (IPJs)
– Proper collateral ligament inserts onto phalangeal base,
more volar accessory collateral ligament onto volar plate
– IPJs should be immobilized in extension to avoid stiffness

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 90 Hand and Peripheral Nerve

b. Grayson’s ligament on both palmar sides of finger, dorsal to

fibrofatty superficial fascia, but palmar to digital neurovascular
bundle
c. Cleland’s ligament on both sides of finger (halfway between volar
and dorsal), palmar to dorsal superficial fascia, but dorsal to neu-
rovascular bundle
d. Volar plate: not truly a ligament
i. Dorsal aspect contiguous with intraarticular IP joint
ii. Volar aspect provides gliding surface for flexor tendons across
IP joints
iii. Thickened lateral portions of the plate form checkrein liga-
ments, anchored to volar periosteum
– Checkrein ligaments: form at confluence of portion of dorsal
flexor sheath, the horizontal reflection of the accessory CL,
and lateral aspect of volar plate
– Protect transverse branch of digital artery and prevent IP
hyperextension
7. Tendons
a. Flexor tendons
i. Anatomy
– At level of wrist, FDP tendons all lie deep (dorsal) in a hori-
zontal plane to FDS tendons, which are layered 2 × 2 with
MF, RF superficial, and IF, SF deeper
– Zones (Verdan)
• Zone I: distal to FDS insertion; contains FDP only
• Zone II: “no man’s land”; from distal palmar crease to
distal insertion of FDS; contains FDP and FDS in narrow
sheath
• Zone III: palm; distal to distal edge of transverse carpal
ligament at origin of lumbricals ending at the distal pal-
mar crease
• Zone IV: carpal tunnel
• Zone V: wrist and distal forearm
– Tendon sheath and pulleys—preservation of A2 and A4 pul-
leys to avoid “bowstringing”
– Tendon nutrient and healing: extrinsic (vincular supply to
FDS and FDP) + intrinsic (intrasynovial diffusion)
– Injury
• Partially severed: repair lacerations >50% of tendon;
débride lacerations <50%
• Rupture
• Avulsion (at FDP insertion = “jersey finger”)
○ Most often ring finger
○ Leddy and Packer classification (Leddy JP, Hand Clin.
1985 Feb;1(1):77–83)

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 Hand and Peripheral Nerve 91

• Type I: retracted into palm, restrained only by lumbrical

origin. Urgent: repair within 7–10 days to maintain blood
supply
• Type II: retracted to PIPJ; not as urgent as blood supply
maintained
• Type III: associated with bony fragment preventing
migration proximal to A4/A5 pulley (DIPJ); again, delayed
repair acceptable
• Type IV: associated with avulsion fx as well, but ten-
don further separates, retracts into palm; urgent repair
indicated
ii. Surgical options
– Primary repair: ideal in most cases
– Delayed primary repair
– Secondary repair: associated with increased scarring, but
may occasionally be indicated
• If performed, single versus two-stage silicone (Hunter)
rod method
• For thumb avulsion, consider delayed Z-lengthening of
FPL at wrist with distal advancement
– Profundus advancement
– Tendon graft
– Tendon transfer
– Arthrodesis
– Capsulodesis
– Tenodesis
iii. Techniques: multiple suture materials and configurations
available
– Skin and tendon sheath incision: use of cruciate synovial
windows C1–A3–C2 and C3–A5
– Pulley dilation
– Tendon retrieval: flexion of wrist and MP joints and milking of
sheath is helpful; use of pediatric feeding tube through fibro-
osseous sheath in retrograde fashion. Modified Kessler-
Tajima suture placed in retracted tendon edge in proximal
cruciate synovial window or palm, suture tails passed into
feeding tube and feeding tube pulled antegrade distally and
tendon then passed distally
– Repair technique (strength increases with number of core
sutures)
• Suture
○ 3–0 or 4–0 Ethibond appropriate for most repairs
• Technique
○ Modified Kessler: used for lacerations >50% in Zone IV
and most other places

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 92 Hand and Peripheral Nerve

• Single suture passed as core, then out transversely, then

back out core in first end. In other end, same pattern
followed, ending up passing out core opposite of where
entered
○ Tajima: often used for flexor tendon repair in replant
cases as allows surgeon to first repair vessels and
nerves in extension (improves exposure), and then
coapt the tendons
• First suture is passed as core, then transversely, then
back out core in one end. A second suture is run the same
way in opposing suture end. The two sutures are then tied
together
○ Horizontal mattress sutures
• Frequently used for repair of FDS or to add core sutures to
above techniques (need at least four to six core sutures
for strength)
○ Epitendinous suture
• Most often performed with a relatively finer (i.e., 5–0)
permanent monofilament such as nylon; this decreases
bulk (helps gliding) and adds up to 20% to repair
b. Extensor tendons
i. Anatomy
– Nine extensor tendon zones
• Zone 1 = DIP joint
○ Mallet finger
○ Type I: loss of extensor tendon continuity from sudden
forceful flexion of DIP +/− avulsion fx of dorsum
■ Most common type
■ Treat with continuous splinting of DIP joint in full
extension for 6–8 weeks; if recurs, splint another
2–3 weeks
○ Type II: loss of extensor tendon continuity from lacera-
tion proximal to or at DIP joint
■ Treat with suture repair (consider running mono-
filament through both skin and tendon) followed by
continuous splinting for 6 weeks
■ Alternately, pin DIPJ in neutral extension following
repair of zones 1 and 2 extensor tendon lacerations
to neutralize the stronger FDP × 4 weeks
○ Type III: loss of extensor tendon continuity from deep
abrasion with loss of skin and soft tissue
■ Treat with staged surgical reconstruction
• Zone 2 = over P2/middle phalanx

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 Hand and Peripheral Nerve 93

• Zone 3 = PIPJ
○ Usually from forced flexion of PIP joint with avusion of
central slip from its insertion on dorsal base of middle
phalanx (+/− avulsion fx)
○ Boutonnière deformity results from avulsion of
central slip with resultant PIP joint flexion and DIP
hyperextension
○ Begins with PIP flexion from unopposed FDS action,
followed by stretching of expansion (transverse reti-
nacular and triangular ligaments) between central and
lateral slips. Lateral bands migrate to become volar
to axis of joint rotation, allowing intrinsic muscles to
pull exclusively on distal joint, hyperextending it. Most
often gradually develops 1–3 weeks after injury
○ Dx
■ As boutonnière deformity is generally delayed, dx
should be suspected with recent injury resulting in
swollen, painful PIP joint with limited ROM, main-
tained in semiflexed position
■ Elson test: passively flex PIP joint over table edge
and maintain in place; ask patient to actively extend
PIP against resistance—any perceived (by exam-
iner) pressure over middle phalanx indicates intact
(at least partially) central slip
○ Tx
■ Closed boutonnière
□ Acute: progressively splint PIP joint into full
extension and/or place oblique transarticular
K-wire to maintain PIP joint in extension. Keep
passively actively ranging DIP joint. Typically do
for 6 weeks. Indications for operation: central slip
avulsion fracture (replace or excise fragment and
reattach tendon with a pullout suture); young per-
son with long-standing boutonnière deformity
■ Central slip laceration at PIP joint: repair with modi-
fied Kessler suture with 4–0 suture, beginning 1 cm
from tendon laceration edge; follow with 5–0 suture
Silfverskiold cross-stitch from margin to margin of
extensor. Suture anchors have aided with repair of
open zone 3 extensor laceration to the central slip
• Zone 4 = over proximal phalanx, primary repair with hori-
zontal mattress or other technique
• Zone 5 = MCPJ, primary repair with horizontal mattress
or other technique
○ Sagittal band injuries: repair if identified

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 94 Hand and Peripheral Nerve

• Zone 6 = over dorsal metacarpals, primary repair with

horizontal mattress or other technique
○ Secretan’s disorder (peritendinous fibrosis): factitious
disorder manifesting as chronic edema and pain
• Zone 7 = under retinaculum: repair tendons as previous,
repair retinaculum
• Zone 8 = myotendinous junction in distal forearm: tendon
bulky enough to use modified Kessler or Tajima technique
• Zone 9 = proximal forearm: use of Vicryl in often used
with horizontal mattress or Mason suture technique
– Six extensor compartments (from radial to ulnar)
• Compartment 1: EPB, abductor pollicis longus (ABL)
• Compartment 2: ECRB, ECRL
• Compartment 3: EPL
• Compartment 4: extensor digitorum (4), extensor indicis
• Compartment 5: extensor digiti minimi
• Compartment 6: ECU
8. Fingernails
a. Anatomy and physiology
i. Root covered by eponychium, distal free area under nail is hypo-
nychium, and the soft tissue around the nail is the perionychium
(along the lateral edges, this is called paronychium)
– Nail is produced by perionychium; germinal matrix gener-
ates 90%; distally, sterile matrix contributes 10% and
“sheen” of nail
– Nail grows on average 3–4 mm/month
b. Injury
i. Lesions in germinal matrix lead to permanent deformity or loss
of nail. If significantly injured, nail bed ablation may be appro-
priate, remembering terminal extensor tendon is only 1.2 mm
deep and proximal to the germinal root
ii. Principles of management
– Remove nail to examine the bed
– Débride only what is necessary
– Stabilize distal phalanx as indicated
– Repair nail bed accurately
– Replace sterile matrix as necessary (can graft from other
finger or toe)
– Replace nail with nail or 0.02" silastic sheet spacer

B. EVALUATION
1. History
2. Physical
(See Table 3.1)

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 Hand and Peripheral Nerve 95
TABLE 3.1
Joint/Motion Muscle Nerve Root
Elbow
Flexion Brachialis Musculocutaneous C5, C6, C7
Biceps Musculocutaneous C5, C6
Extension Triceps Radial C6, C7, C8
Forearm
Biceps Musculocutaneous C5, C6
Supination Supinator Radial C7, C8
Pronation Pronator teres Median C6, C7
Pronator quadratus Ant interosseous C7, C8
branch of median
Wrist
Flexion Flexor carpi radialis Median C6, C7
Flexor carpi ulnaris Ulnar C7, C8, T1
Extension Extensor carpi radialis longus Radial C6, C7
Extensor carpi radialis brevis Radial C7, C8
Extensor carpi ulnaris Radial C7, C8
Finger (MCP)
Flexion Medial two lumbricals Ulnar C8, T1
Lateral two lumbricals Median C8, T1
Extension Extensor digitorum communis Post interosseous C7, C8
branch of radial
Extensor indicis Post interosseous C7, C8
branch of radial
Extensor digiti minimi Post interosseous C7, C8
branch of radial
Abduction Dorsal interossei* Ulnar C8, T1
Abductor digiti minimi Ulnar C8, T1
Adduction Palmar interossei* Ulnar C8, T1
Finger (PIP)
Flexion Flexor digitorum superficialis Median C8, T1
Extension Extensor digitorum communis Post interosseous C7, C8
branch of radial
Extensor indicis Post interosseous C7, C8
branch of radial
Extensor digiti minimi Post interosseous C7, C8
branch of radial
(continues)

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 96 Hand and Peripheral Nerve
TABLE 3.1 (continued)
Joint/Motion Muscle Nerve Root
Finger (DIP)
Flexion Flexor digitorum profundus Ulnar; Ant inteross C8, T1
branch of median
Extension Extensor digitorum communis Post interosseous C7, C8
branch of radial
Extensor indicis Post interosseous C7, C8
branch of radial
Extensor digiti minimi Post interosseous C7, C8
branch of radial
Thumb
Palmar abduction Abductor pollicis longus Radial C7, C8
Abductor pollicis brevis Median C8, T1
Dorsal abduction Adductor pollicis Ulnar C8, T1
Thumb MCP
Flexion Flexor pollicis brevis (FPB; Ulnar C8, T1
deep head)
FPB (superficial head) Median C8, T1
Extension Extensor pollicis brevis Radial C7, C8
Thumb IP
Flexion Flexor pollicis longus Median C7, C8
Extension Extensor pollicis longus Radial C7, C8

* Interossei also flex MCP and extend PIP and DIP.

MCP = metacarpophalangeal joint
PIP = proximal interphalangeal joint
DIP= distal interphalangeal joint
IP= interphalangeal joint
Source: Adapted from JR Doyle, Orthopaedic Surgery Essentials: Hand & Wrist, Lippincott Williams &
Wilkins, Philadelphia; 2005, p. 12

3. Radiography
a. Three standard views
i. Frontal (PA): hand flat, palm down, forearm pronated
ii. Oblique: from PA position, supinate hand 45° (step sponge
helps maintain IP joint orientation/spread)
iii. Lateral: hand rotated further into radioulnar projection with
fingers spread

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b. Individual fingers should be imaged as appropriate

i. Thumb frontal radiograph obtained with forearm overpronated,
with thumb dorsum on cassette
– Thumb lateral radiography obtained with hand overpronated,
with radial surface on cassette
ii. For wrist, three standard views are often supplemented with
scaphoid view
– Scaphoid view performed with wrist in PA position, then
ulnarly deviated as far as possible and beam angled toward
elbow. This provides perpendicular view to long axis of
scaphoid, especially good for scaphoid waist
• Alternate way to image scaphoid is with fingers elevated
off cassette w/ sponge with beam perpendicular to film
c. Other useful views
i. Carpal tunnel view: wrist hyperextended with either palm or
volar wrist on cassette (variable angle of beam)
– Profiles the hamate hook, pisiform, carpal tunnel, and volar
aspect of trapezium
ii. Clenched fist, ulnar deviated views useful for scaphoid pathol-
ogy (former for SLIL injury, latter for fx)
iii. Brewerton views: useful to evaluate metacarpal heads
iv. Roberts’ views: useful for evaluating first CMC, first metacar-
pal base
d. On neutral PA view, either the scapholunate or lunotriquetral joint is
clearly imaged, depending on amount of pronation
i. Important measurements
– Radial angulation: angle between distal radial articular
surface (PA view) to a line perpendicular to long axis of
radius (nl 15–25°). A decrease in this angle suggests distal
radial fx, likely with fragment overlap or impaction.
– Palmar tilt: angle between distal radial articular surface
(lateral view) and line perpendicular to long axis of radius
(nl 10–25°)
– Ulnar variance: comparison made on PA view between
length of radius and ulna at lunate articulation. If ulna is
shorter, termed “negative” ulnar variance. Varies with pro-
nation/supination of forearm.
– Gilula’s lines: three radiographic carpal arcs that identify
normal intracarpal alignment (Gilula LA, Am J Roentgenol,
1979;133(3):503–17)
• Arc I: outlines proximal margins of scaphoid, lunate, and
triquetral bones
• Arc II: outlines distal margins of scaphoid, lunate, and
triquetral bones
• Arc III: outlines proximal margins of capitate and hamate
bones

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 98 Hand and Peripheral Nerve

e. CT: useful for evaluating complex or occult fractures

f. MRI: useful for soft tissue, ligamentous structures, as well as
evaluating viability, osteomyelitis

C. FRACTURES AND DISLOCATIONS

1. General
a. Epidemiology: hand fx’s are the most common (regardless of age,
sex, nationality); most often on right, in males, involving radius a/o
ulna, and in ages 5–14
b. Evaluation: always evaluate for possible ligamentous, tendinous,
nerve, and/or vascular injury. Three views on X-ray typically required
c. Fracture patterns and nomenclature
i. Greenstick: seen only in children, involves only one side of cortex
ii. Transverse: from direct blow to shaft, generally more stable
than an oblique fracture
iii. Oblique: from direct axial loading, generally less stable than a
transverse fracture
iv. Spiral: from excessive rotational stress during axial loading
v. Comminuted: more than two bone edges are involved (frag-
ments created not in continuity with remainder of bone)
vi. Angulation (determined by direction of force and pull of
muscles)
– Metacarpal fractures: usually dorsal angulation
– Phalangeal fractures: usually volar angulation
2. Reduction, fi xation, and immobilization
a. General principles
i. Immobilize only joints that are absolutely required. Immobilize
joints above and below
ii. Usually should immobilize wrist extended and fingers in “intrin-
sic plus” position to minimize collateral ligament shortening
(MCPJs flexed 70–90°, IPs straight)
iii. Early mobilization and elevation (i.e., 30 cm above heart)
important to prevent pain and stiffness from edema
iv. Fx’s tx’d with closed reduction should generally be mobilized
after 3–4 weeks, even in absence of radiographic union (fibrous
union is protective at this stage)
v. Surgery is indicated for: open fractures, articular step-off,
bone loss, significant shortening, failure of closed reduction,
multiple fractures (relative), intrinsic instability, persistent
rotational malalignment (usu. oblique and spiral fx), and asso-
ciation with joint subluxation or dislocation
vi. Choice of technique must weigh stability against invasiveness
and potential injury to blood supply and soft tissue
– Plates: associated with stiffness in phalangeal fx
– Screws: compression screws useful for oblique fx

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 Hand and Peripheral Nerve 99

– Kirschner wires (K-wires): smooth wires adversely affect

soft tissue less than threaded. Place so as to allow soft-
tissue gliding during rehab. If transarticular, must pro-
tect with splint/cast to prevent breakage. 0.045" K-wires
placed perpendicular to fx line useful for oblique fx.
Generally appropriate to make 90° bend on exposed end,
then cut 2 mm beyond this
b. Metacarpal fractures
i. Closed management
– After nerve block, extend wrist and apply longitudinal trac-
tion (grasp flexed proximal phalanx) then correct deformity
to appropriate alignment and rotation. Jahss maneuver for
metacarpal neck fractures
– Obtain postreduction radiographs
– Maintain reduction with cobra splint or cast for 3–4 wks,
with wrist extended and MCPs flexed 80–90°
• Leave PIPJs free (Burkhalter splint)
– Reduction: use articular surface of proximal phalanx to
push against and reduce the volar flexed metacarpal head/
neck (Jahss maneuver)
ii. Isolated metacarpal neck/shaft fx. Multiple fixation techniques:
transmetacarpal pinning: place two parallel percutaneous pins
through reduced distal part of fx into adjacent—avoid collat-
eral recesses that mark collateral ligament origins metacarpal
to maintain reduction; intramedullary K-wires (bouquet pin-
ning antegrade technique, retrograde intramedullary pinning;
crossed pinning). Plate/screws for comminuted fxs, open frac-
tures, combined injuries. External fixation consider for bone
loss, infected/contaminated cases
iii. Diaphyseal fx
– Functionally, 40–50° of angulation in ring, little fingers
acceptable (compensatory CMC motion), but cosmetically
not accepted by most patients
– No rotation is acceptable (look for scissoring of flexed fin-
gers on exam), but up to 4 mm of shortening is OK
– Stabilization options
• Cast, K-wires (parallel or crossed; bicortical passage
recommended to prevent rotation), screws (i.e., compres-
sion screws at right angles to oblique fx), screws and
plates, external fixator
iv. Base fx
– Usually involve ring and little finger, and associated w/ fx
of adjacent carpal bones (check oblique supination view if
have carpal fx to evaluate for occult base fx)
– ORIF indicated to restore alignment of CMC articular sur-
faces and correct CMC subluxation

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v. Thumb metacarpal fx
– Diaphyseal: uncommon, and because of the thumb’s con-
siderable CMC motion, dorsal angulation relatively less
important functionally than in the fingers (up to 30° usually
tolerated, although not aesthetically)
• Immobilize in CMC abduction and extension w/slight MCP
flexion and IP extension. Difficult to control nonopera-
tively given tendon pull. CRPP preferred over ORIF
– Base
• Extraarticular epibasilar: tx like diaphyseal fx (most often,
closed is acceptable)
• Intraarticular: challenging
○ Bennett’s (intraarticular) fx: CRPP versus ORIF. If
ORIF, use Wagner incision/exposure. If fragment large
enough, can use screws
○ Rolando’s fx: a comminuted intraarticular fracture of
the base of the thumb metacarpal (originally described
as having a Y- or T-shaped intraarticular component)
• In those with Y- or T-shaped intraarticular components,
ORIF w/K-wires, plates, and screws indicated. Fixed
angle plates (i.e., miniblade plates or locking plates) may
be advantageous
• In more comminuted fx, additional techniques such as
skeletal traction and mini-external fixators may be useful
c. Proximal phalanx
i. Closed management
– After nerve block, apply longitudinal traction if shortening
present, then correct deformity
– Deforming forces of intrinsic muscles can be minimized
with flexion of MCP
– Test stability of reduction and rotational alignment.
Tenodesis maneuver is performed and digital cascade is
compared to the contralateral side.
– Obtain post reduction radiographs
– Radial or ulnar gutter splint may be appropriate for
immobilization
• Alternatively, immobilize wrist/hand in extension with
reduced digit on outrigger splint w/MCP flexed 90°, PIP
extended
• Facilitates visual and radiographic evaluation of alignment
• Stable, minimally displaced, appropriately aligned fx’s
may be managed by taping/strapping to adjacent finger
and permitting protected motion relatively early
– Intrinsic plus position: diminishes deforming forces of
intrinsic muscles and avoids MCP/PIP collateral ligament
contracture

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• Wrist extended
• MCP flexed to 70–90°
• PIP extended
• 3–4 weeks after reduction, begin (protected) motion, w/
continued splinting prn
– Periarticular (PIPJ): requires reduction and stabilization.
Dynamic external fi xation can be helpful in complex articu-
lar fractures of the base of P2 (i.e., “pilon fractures”)
– Periarticular (MCPJ): internal fixation with protected early
motion recommended
– Diaphyseal: tend to angulate apex volar due to intrinsic
muscles and extensor mechanism
• Reduce by applying axial traction pulling on flexed MCP,
accentuation of deformity to disengage fragments, then
correct
• Tx: CRPP versus ORIF
d. Middle phalanx
i. Closed management principles generally the same as for proxi-
mal phalanx fx
ii. Nondisplaced, extra articular: buddy tape 3–4 weeks. Spiral fx
are rotationally unstable and often require fixation, CRPP ver-
sus ORIF.
iii. Displaced a/o articular: unstable fx
iv. Dorsal fx subluxation of PIP: treatment predicated on size
of volar articular fragment; <30% articular surface stable,
30–50% tenuous, >50% unstable
v. Extremely disabling, comminuted, unstable fx – tx options
– Dynamic traction to maintain reduction while permitting
joint motion useful for complete articular pilon fractures
– Dorsal block splinting in a degree of flexion to maintain
concentric reduction: gradually extend the splint angle over
4–5 weeks, useful when PIPJ joint reduced and concentric
in flexion
– Late injury may require volar plate arthroplasty versus
hemi-hamate arthroplasty
– Cases involving the thumb may be managed with thumb
spica cast or splint or ORIF w/ K-wires, plates, a/o screws
e. Distal phalanx (most common hand fx)
i. Tuft: often associated with subungual hematoma
– Drain subungual hematoma if painful
– If significant damage to nail/nail bed, consider repairing
bed with fine absorbable suture
– If nail is not too damaged, consider replacing as a biologic
stent

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– DIP splinting for 2–3 weeks may give symptomatic relief.

Nonunion is common, but usually is asymptomatic and does
not require specific tx. Fibrous union is often seen
ii. Shaft
– Usually minimally displaced. 2–3 weeks of DIP splinting
being usu. adequate tx. If diaphyseal fx is displaced, sug-
gests underlying matrix laceration. Rx: matrix repair and
ORPP P3 fx
iii. Proximal metaphysis
– Reduce nail and suture fix in place if displaced.
Transarticular K-wire often useful to maintain reduction
iv. Base of distal phalanx
– Type I: transepiphyseal separation with associated nail
plate avulsion is commonly seen in children, with extensor
mechanism attached to epiphyseal base; this is an open
fracture and urgent irrigation/débridement, fracture reduc-
tion/stabilization with transarticular K-wire fixation recom-
mended. Associated with germinal matrix root avulsion,
which requires repair
– Type II: hyperflexion injury involving 20–50% of articular
surface (mallet fx). Operative tx generally advocated >1/3 of
articular surface involved (some maintain that splinting is
acceptable); technically challenging, this usually involves
passing double-ended K-wire through DIP w/ splinting
for 6 weeks. 4–0 wire can additionally be looped over
avulsed fragment dorsally, then brought out palmarly and
tied to button to maintain reduction (remove in 3–4 wks).
Stainless cerclage wire favored by some. Dorsal extension
block pinning technique is simpler
– Type III: hyperextension injury usually involving >50% of
articular surface, may be associated with volar subluxation
of distal phalanx. Tx as a Type II injury
f. Ligamentous injury
i. Thumb
– Ulnar collateral ligament rupture
• Injured more frequently than radial collateral ligament
• May be associated with Stener lesion, where adductor
aponeurosis becomes interposed between completed
disrupted ends of UCL
• Dx: clinical usually adequate
○ Tenderness over ulnar aspect MCPJ, ecchymosis, lax-
ity with radial stress (may need to block radial and
median nerves to allow exam)
○ Incomplete tear: <30° absolute, <15° difference with
contralateral UCL laxity, and discrete end point
○ Complete: >30° UCL laxity, >15° difference with con-
tralateral UCL, and no definable end point

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• Tx: depends on severity

○ Incomplete: immobilize MCPJ 4 weeks in neutral varus/
valgus and mild flexion. Short arm thumb spica cast,
leave IP free
○ Complete: surgery indicated, particularly if presence
of Stener lesion; chronic lesions may require tendon
graft either woven in or anchored to bone
• Volar plate often requires evaluation in complete lesions
as well
g. Replantation
i. Prior to surgery: recommend transport finger in bag that is sur-
rounded by ice
ii. Indications
– Children: virtually always
– Adults: thumb, high-demand profession (professional
musician), multiple digits
iii. Contraindications: prohibitive systemic morbidity, single finger,
zone II, multiple levels of injury. Crush and avulsion injuries
less likely to survive than clean severance. Prolonged ischemia
time (e.g., 24 hours).
*Note: In some Asian cultures such as Japan, exceptionally high value placed
on finger integrity, lowering threshold for replantation attempts.
iv. Approach: for multiple replantations, generally repair ordered
components of each digit rather than repair entire digits serially
v. Order: bone K-wires, screws, plate/screws, intraosseous wiring,
acute arthrodesis as dictated by nature and level of bony injury
→ flexor tendons → extensor tendons → nerves →arteries →
veins
– Exception: if digits are in varying conditions, then replant
the best digit first (may be indicated to place orthotopically,
i.e., replant index finger in ring finger position)
vi. Postoperative care: immobilization, elevation, thrombolytics
(at least aspirin, most surgeons also use systemic heparin for
3–5 days); keep patient warm and comfortable; no nicotine or
caffeine
h. Dislocations
i. Perilunate: high-energy injuries. Examine for associated mus-
culoskeletal and neurovascular injuries with particular focus
on median nerve symptoms
– Reduction
• Closed (Tavernier’s method): performed under conscious
sedation
○ Apply axial traction on slightly extended wrist
○ Stabilize the lunate volarly with your thumb, then
slowly flex the wrist while maintaining traction
○ “Snap” represents proximal pole of capitate sinking
back in concavity of lunate, passing over dorsal lip

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• Open (treatment of choice following emergent closed

reduction)
○ Dorsal approach via 3–4 extensor compartment interval
○ Consider placing K-wire into lunate and scaphoid to
use as a joystick to correct associated DISI dorsiflexed
posture of lunate secondary to SLIL disruption. Suture
anchors for SLIL repair. Consider concomitant dor-
sal capsulodesis to augment repair. Reduce and pin
lunotriquetral (LT) interval. Associated scaphoid fxs
are treated with ORIF. Consider concomitant carpal
tunnel release
– Fixation
• Percutaneous pin fixation should follow closed reduction
(one to two pins through scapholunate and scaphocapi-
tate, and one through lunotriquetral)
• Splint for 8–12 weeks postreduction
i. MCPJ
i. Dorsal (much more common than volar)
– Simple (proximal phalanx extended 60–80°)
• Flex wrist and phalanges to relax flexor tendons, then
apply distal and volar traction to base of phalanx
– Complex: irreducible due to volar plate interposing in joint
space, or lasso effect of FDP or lumbrical
– Requires release of A1 pulley when done through volar
approach, some advocate dorsal approach
– Postoperatively, immobilize MCPJ in 30° flexion for 2 weeks,
follow by AROM with 10° dorsal blocking splint for 2 weeks
j. Carpal
*Note: New median nerve distribution changes after acute carpal fractures
or other high-energy trauma is an indication for nerve decompression/
exploration.
i. Scaphoid
– Most commonly fractured carpal bone, usually through
waist. Mechanism usually falls on extended wrist
– Blood supply enters from distal pole that gives off intraos-
seous branches to proximal pole. Proximal pole fractures
heal more slowly with higher risk nonunion and avascular
necrosis
– Dx
• Hx often of fall on extended wrist with complaints of per-
sistent wrist pain
• Exam: “anatomic snuffbox” tenderness (between EPL
and APL/EPB tendons)
– Radiographs
• Standard wrist series with scaphoid view (PA wrist w/
patient making fist—extends and slightly ulnarly devi-
ates wrist), true lateral, and two oblique views

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 Hand and Peripheral Nerve 105

• Nondisplaced fx may not be immediately apparent on

plain films; if high index of suspicion, immobilize wrist in
short arm spica cast and repeat X-rays in 2–3 weeks
○ If repeat plain films are nondiagnostic, and index of
suspicion high, consider MRI, CT (or bone scan, which
is currently less commonly used)
○ Gadolinium-enhanced MRI may be used to evaluate
vascular sufficiency of scaphoid (debated in ortho/
radiology literature)
○ CT scan helpful in assessing intrascaphoid deformity
and nonunion. Be sure to request scaphoid protocol w/
reconstructions along the axis of the scaphoid
– General principles
• Stable, nondisplaced, waist: immobilize
○ ~100% distal pole fx heal; 80–90% waist fx heal;
60–70% proximal pole fx heal
○ Historically, initial long arm (above elbow) thumb spica
cast for 6 weeks followed by short arm thumb spica
cast. Many start with short arm thumb spica. Some
European literature suggest excluding the thumb does
not impact healing rates
○ Cast immobilization much less successful if delay of
treatment >4 weeks
○ Nondisplaced fx may also be managed with percutane-
ous screw fixation
○ Displaced or unstable fx require ORIF
• Instability defined in part by gap or fracture offset of ≥
1 mm
• ORIF usually appropriate for all proximal pole fx due to
high incidence of nonunion
• Bone graft acute, severely comminuted fx
• Electrical stimulation may be of benefit for delayed/
nonunion
– Based on location
• Distal third and tuberosity fx: as previous, short arm
spica cast indicated unless intraarticular and displaced
(ORIF appropriate)
• Middle-third fx: stable, undisplaced fx get short arm
spica cast as previous
○ Potentially unstable fx (vertical oblique, transscaphoid
perilunate fracture dislocations) get long arm thumb
spica cast. ORIF recommended for reduced transscaph-
oid perilunate fracture dislocations.
○ Displaced or angulated fx get ORIF (headless compres-
sion screws. K-wires may be needed for small proximal
pole fractures or in children)

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 106 Hand and Peripheral Nerve

• Proximal third fx: headless compression screw via dorsal

approach followed by thumb spica cast
○ Because of tenuous blood supply to proximal pole,
even w/ appropriate tx, delayed union, nonunion, or
avascular necrosis frequently occur, requiring revi-
sion surgery that may include vascularized bone
grafting, or proximal pole excision (limited indica-
tions). Salvage procedures such as proximal row car-
pectomy or scaphoid excision four-corner fusion are
indicated when posttraumatic degenerative changes
are seen as a result of scaphoid nonunion (scaphoid
nonunion advanced collapse [SNAC] wrist changes)
– Approaches and surgical principles
• Palmar or anterior approaches preferred for distal pole
and waist fx as vascular supply to scaphoid from dorsal
and distal pole. Palmar approach also preferred for tx of
“humpback” deformity from scaphoid collapse with apex
dorsal deformity/volar angulation
• Dorsal approach generally best for placing screw in proxi-
mal pole fx (limit dissection to proximal pole) as well as
for placement of vascularized bone graft
– Complications
• Nonunion
○ SNAC stages: arthritis of radial styloid → spread of
arthritis to scaphoid fossa of radius → development
of capitolunate arthritis → diffuse carpal arthritis
• Malunion
• Arthrosis
• AVN
• Subsequent waist fx with apex dorsal/volar angulation
and “humpback” deformity
k. Carpal instabilities and fracture dislocations
i. Scapholunate instability (most common wrist instability)
– Tear of scapholunate ligament suggested by widened
(≥3 mm) scapholunate interval (Terry Thomas sign) on PA
and dorsal angulation of lunate on lateral X-ray (DISI).
Lunate firmly attached to both scaphoid and triquetrum by
interosseous ligaments; if ligament torn to one of the other
two bones, lunate rotates with the other (scaphoid → volar,
triquetrum → dorsal)
– Scapholunate angle: normal 30–60° (usu. 46–47°)
• >60° suggests scapholunate ligament injury (DISI)
• <30° suggest lunotriquetral ligament injury (volar inter-
calated segment instability [VISI])
• Radiolunate angle: normal 0–11°

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 Hand and Peripheral Nerve 107

– Physical findings
• Tenderness just distal to Lister’s tubercle
• Watson shift test positive
– Acute (within 3 months of injury) and reducible
• Repair scapholunate ligament and buttress with dorsal
capsulodesis
○ Ligament reconstruction with FCR tendon (Brunelli-
type reconstruction), bone ligament bone construct,
“Reduction and Association of the Scaphoid and
Lunate” (RASL) procedure are other options
– Chronic (after 3 months of injury) irreducible
• Untreated dorsal intercalated segment instability (DISI)
pathology can degenerate into scapholunate advanced
collapse (SLAC) wrist over time
• Ligament cannot be repaired, and arthritic changes often
present
• Options
○ Proximal row carpectomy: good pain relief, (usu.) w/
preservation of ~75% grip strength and ~55% ROM
versus scaphoid excision with four-corner fusion
○ Wrist arthrodesis: consider if lunate fossa of radius or
capitate head are arthritic

D. INFECTION AND INJECTION

1. Infection
a. Cellulitis: nonsurgical condition, manage with antibiotics only
b. Paronychia: infection of the nail fold
i. Early: warm soaks, hand elevation, splinting, antibiotics
ii. Suppurative: must drain pus, requires elevation of nail and
often excision of at least a portion of the nail plate to ensure
decompression
iii. Chronic: usually associated with C. albicans
c. Felon: infection of pulp space of distal phalanx; most often treated by
incising/draining the most fluctuant point with longitudinal incision
d. Tendon sheath infection (tenosynovitis)
i. Acute
– Flexor
• Kanavel’s signs
○ Tenderness along volar finger (over tendon sheath)
○ Extreme pain with passive extension
○ Finger maintained in semiflexed position
○ Fusiform “sausage-like” swelling of entire finger
• Tx: emergent incision and irrigation of the flexor sheath.
Release of A1 and A5. Catheter can be fed through
fibroosseous sheath and sheath is flushed with irrigation
○ Antibiotics tailored to cx

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 108 Hand and Peripheral Nerve

– Extensor: emergent treatment. Extensor compartments can

be opened proximal and distal to extensor retinaculum to
prevent bowstringing and the compartment is irrigated and
tenosynovectomy performed as needed
e. Chronic
i. Mycobacterial (most often M. marinum)
– Clinically, may find proliferative synovitis and “rice bodies”
(infected villous bodies that break loose)
– Pathology rarely specific, but may demonstrate granulomas
– Culture tissue sample at 30°C for M. marinum
f. Deep space infections: includes subtendinous space of Parona in
the distal volar forearm, the midthenar and hypothenar spaces, and
the dorsal subaponeurotic space between the extensor tendons and
dorsal interossei fascia. Be aware of collar button abscesses in the
web spaces and pantaloon abscess in the first web tracking along
the fascial margin of the adductor aponeurosis
g. Septic joint: requires emergent decompression, irrigation, and anti-
biotic therapy
h. Bite wounds: Unasyn or Zosyn good IV tx, Augmentin good PO tx for
most; surgery almost invariably should be débridement, not primary
closure
i. Human: “fight bites” over dorsal MCPJ often cause partial
extensor laceration and traumatic arthrotomy through the
dorsal capsule of the MP joint. Require surgical irrigation/
débridement
– S. aureus most common organism, Bacteroides is common
anaerobe genus found in such wounds, Eikenella corrodens
somewhat unique to these wounds
ii. Cat: 50% become infected; alpha-hemolytic Streptococcus and
Pasteurella multocida frequently cultured
iii. Dog: one-third become infected; similar concerns and patho-
gens as with cat bites; fortunately, less inoculum typically
involved as teeth not as sharp
i. Other
i. Herpetic whitlow: HSV infection often involving dorsal skin near
nail, may mimic paronychia. Tx is NOT surgical, but with antivi-
ral agents such as acyclovir
2. Injection
a. Often from paint gun injuries (oil-based more toxic than water-
based), usually involves index finger
b. Emergency cases
c. Use Brunner incisions versus midaxial in fingers
d. Meticulous neurovascular dissection and débridement of foreign
material key
e. High risk of amputation: discuss w/ patient preoperatively

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 Hand and Peripheral Nerve 109

E. INFLAMMATORY AND DEGENERATIVE DISORDERS

1. Dupuytren’s disease
a. Epidemiology and etiology
i. Affects 0.2% of population; more common (2x) and intense in
men; most often in ages 40–60
ii. Genetics: inheritable in AD fashion w/ variable penetrance and
associated with HLA-DRE as well as trisomy 8
– Linked to descendants of Vikings and Celts
iii. Environment: associated w/ chronic alcoholism, epilepsy, dia-
betes, cigarette use, HIV, s/p MI
b. Pathoanatomy and pathophysiology (involves myofibroblast activity)
i. Three stages
– Proliferative (nodule formation)
– Involutional (longitudinal band formation)
– Residual (contracted cords)
ii. Structures involved: pretendinous bands, spiral bands, lateral
digital sheet, Grayson’s ligament, natatory ligament
iii. Structures not involved: superficial/deep transverse ligaments,
Cleland’s ligament, Landsmeer ligament
iv. Contractures
– MCPJ: usually secondary to pretendinous cord
– PIPJ: usually secondary to spiral cord (notorious for volarly
displacing neurovascular bundle)
– DIPJ: secondary to retrovascular cord
– Web space contractures: adduction deformities secondary
to natatory cord
v. Other
– Palmar fibromatosis in females may be associated with
ovarian cancer (pelvic U/S or CT scan recommended)
c. Treatment
i. Nonsurgical
– Medication: allopurinol, colchicines, calcium channel block-
ers, gamma-interferon. Intralesional injection of steroids
may be useful for painful, tender nodules. XRT
– Other: skeletal traction of 2 mm/day using TEC device for
2 weeks (Messina A, Messina J, Plast Reconstr Surg,
1993;92(1):84–90
– Collagenase (Xiaflex): level 1 evidence w/ recent trials
demonstrating efficacy of this enzyme. Useful for MCPJ and
PIPJ cords but not for nodular form of disease. Risk of flexor
tendon rupture associated with use at small finger PIPJ level
in early trials

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 110 Hand and Peripheral Nerve

ii. Surgical (patient must be advised that surgery is not curative;

Dupuytren’s disease will almost always recur to some degree
within 10 years)
– Indications: IP or MP contracture with functional disability;
MP contracture >30° (fail table top test); any PIP flexion
contracture; significant web (esp. thumb) contracture;
decreased neurovascular function (from spiral cord entrap-
ment); loss of articular cartilage; synchronous trigger finger
– Contraindications: maceration; infection; poor patient
compliance; concomitant hand arthritis, which may be
adversely affected with surgery.
*Note: nodules not causing significant contracture and knuckle pads not
causing pain or functional problems should not be excised. Also,
pain alone is not an indication for surgery.
– Techniques
• Incisions: McIndoe, Iselin, Skoog, Palmen
• Excision: subcutaneous fasciotomy, fasciectomy,
dermofasciectomy
• Complications: hematoma (most common), skin flap
necrosis, neurovascular injury
• Salvage procedures: arthrodesis for severe, recurrent
contractures
d. Avascular necrosis
i. Kienböck’s disease: lunate AVN, controversial association with
ulnar negative variance. Many treatment options (immobili-
zation, vascularized bone grafting, etc.), which are based on
stage of lunate involvement.
ii. Preiser disease: idiopathic avascular necrosis of scaphoid, rare
e. Arthritides
i. Osteoarthritis: most commonly involves DIPJ for which arthrod-
esis is mainstay of therapy; arthroplasty may be indicated for
PIPJ disease
– Involvement of first CMC particularly common in women.
Initial treatment is often short opponens splinting. Surgical
therapy depends on Eaton classification, but most often
involves ligament reconstruction and tendon interposition
(LRTI) trapeziectomy with placement of spacer (e.g., ½ FCR
tendon) +/− reconstruction of volar beak ligament (e.g., ½
FCR tendon)
– Rheumatoid arthritis: most commonly involves MCPJ
• Treatment: modern immunomodulatory medications have
made surgical intervention much less common
• Operative
○ Goals: eliminate pain > improve function > improve
cosmesis
○ Sequence: proximal to distal

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 Hand and Peripheral Nerve 111

• Tendons: tenosynovectomy if refractory tenosynovitis (>6

months) to prevent tendon rupture)
○ Mannerfelt lesion: FPL rupture due to attritional wear
over scaphoid osteophyte
• Wrist: arthrodesis most commonly performed procedure,
although tenosynovectomy and DRUJ resection may help
alleviate pain
• MCP joint: silicone arthroplasty and joint/tendon balanc-
ing procedures to correct ulnar drift commonly performed
• IP joints: severe disease often only amenable to arthrodesis
• Thumb: arthrodesis may improve function at MCPJ and/or
IPJ
2. Gout
a. Periarticular pain from urate crystal precipitation
b. Dx: aspiration for crystal (negatively birefringent) evaluation
(send in alcohol, not formaldehyde). Uric acid level not diagnostic.
Frequently mimics abscess, osteomyelitis
c. Tx
i. Medical: NSAIDs, allopurinol, colchicines, intraarticular steroid
ii. Surgical: débridement of tophi +/– soft tissue coverage may be
indicated for tophaceous gout; articular destruction may war-
rant arthrodesis
3. Tenosynovitis
a. De Quervain’s tenosynovitis
i. Inflammation of first dorsal compartment
ii. Dx: (+) Finkelstein’s test; swelling, tenderness along first dor-
sal compartment may also be seen
iii. Tx: long opponens splint, cortisone injection, first dorsal com-
partment release

F. TUMORS
1. General
a. When operating on upper extremity malignancies, do NOT use
Esmarch before tourniquet; instead, elevate the arm and compress
brachial artery for 1 minute
2. Soft tissue
a. Benign
i. Ganglia: most common soft tissue tumor of the hand
– Location
• Dorsal (~70%): most often from scapholunate ligament
• Volar (~20%): most often from radiocarpal joint or sca-
photrapezial joint capsule
• Can also occur along flexor tendon sheath of A1 pulley,
termed retinacular ganglion

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 112 Hand and Peripheral Nerve

• “Mucous cyst” refers to dorsal lesion related to degen-

erative changes at DIPJ; excise along with any associated
osteophyte
– Dx: exam is nonpulsatile, transilluminates
– Tx
• Nonoperative: aspiration, blunt rupture, corticosteroid
injection less effective than surgical extirpation
• Operative: treatment of choice, for those with persistent
sx, includes excision of stalk
ii. Giant-cell tumor of tendon sheath: second most common hand
tumor
– Typically arises along volar aspect of fingers, 10% erode
into bone; recurrence after surgery up to 30%; recommend
excising margin of normal tissue
iii. Glomus tumor
– Most often subungual, represent proliferation of vascular/
smooth muscle tissue
– Dx: classically tender and sensitive to cold, MRI useful
adjunct
– Tx: excise along with nail bed followed by nail bed repair
iv. Neurogenic tumors
– Neurilemmoma (schwannoma): most common peripheral
nerve tumor; well-demarcated within nerve and shells out
relatively easily; increased signal on T2 MRI
– Neurofibromas: consists of Schwann cells, fibroblasts, perineu-
ral cells. Much more difficult to excise than neurilemmomas,
post op neuro deficits not uncommon. Rapid growth, pain, or
large size suggestive of possible malignant degeneration
b. Malignant
i. Cutaneous malignancies (see skin chapter)
ii. Sarcoma
– Epitheloid: most common variant distal to elbow; unlike
other sarcomas, lymph node spread not uncommon (syno-
vial sarcoma also shares this feature)
– Clear cell, malignant fibrous histiocytoma, leiomyosarcoma,
liposarcoma, rhabdomyosarcoma represent other types
potentially encountered
2. Bony
a. Benign
i. Enchondromas: most common primary tumor of hand bones,
usually in proximal phalanx; curettage is generally appropriate
– Multiple enchondromas
• Ollier’s syndrome: risk of malignant deneration 25%
• Maffucci syndrome: essentially Ollier’s + hemangiomas;
risk of malignant degeneration >75%

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 Hand and Peripheral Nerve 113

ii. Bone cysts

– Aneurysmal bone cysts: manifest with swelling, pain, pos-
sible fx, usually in metacarpals. Curettage and grafting
appropriate, but has significant recurrence rate (>1/3)
– Unicameral: rare in hand
iii. Osteoid osteoma: most often in phalanges, classically pres-
ent with dull ache that is worse at night and ameliorated with
salicylates; curettage or excision appropriate
iv. Osteoblastoma: uncommon in hand; recurrence in up to 1/3 after
curettage
v. Giant-cell tumor of bone: uncommon in hand; dx confirmed by
incisional bx; decurrence common; tx with curettage v; WLE fol-
lowed by grafting
b. Malignant
i. Chondrosarcoma: most common bone sarcoma in hand. WLE
recommended; chemo, XRT not helpful. Metastasis uncommon
ii. Osteosarcoma: rare in hand. X-rays may demonstrate perios-
teal reaction and new bone formation. Pre- and post-WLE che-
motherapy advocated
iii. Ewing’s sarcoma: lytic lesion with periosteal reaction common,
may mimic osteomyelitis. WLE indicated +/− chemo +/− XRT
iv. Metastatic: most often (50%) bronchogenic origin
3. Peripheral nerves and tendon transfers
a. Peripheral nerves
i. Structure
– Layers
• Epineurium (layer most often sutured in repair)
• Perineurium
• Endoneurium
– Fascicles
– Sensory receptors
• Meissner’s corpuscle
• Pacinian corpuscle
• Merkel cell
– Microanatomy
• Variants
○ Riche-Cannieu anastomosis between the deep branch
of the ulnar nerve and the recurrent motor branch of
the median nerve in the palm
○ Martin-Gruber anastomosis of motor fibers from the
median to ulnar nerve in the forearm
ii. Nerve injury
– Pathology: see Figure 3.1

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 114 Hand and Peripheral Nerve

Seddon Sunderland Lesion Usual Course Management

Neurapraxia I Physiologic Spontaneous Expectant (unless

“block” but recovery in if so proximal
anatomic 1–3 weeks that muscle
disruption reinnervation
not likely within
12–18 months)

Axonotmesis II Axon disruption; Spontaneous Expectant; surgery

other layers recovery; may be required
intact generally at for scar lysis
1 mm/day
after initial
lag period

III Axon and Spontaneous Surgery may be

endoneurim recovery possible required
disruption; (~70%), limited
preserved largely by scar
perineurium formation

IV Disruption of all No spontaneous Surgery (usu.

layers except recovery grafting)
epineurium required

Neurotmesis V Complete nerve No spontaneous Surgery (usu.

distruption recovery grafting) required

FIGURE 3.1 Summary of peripheral nerve injury

iii. Diagnosis
– Nerve conduction studies (NCS)
• Latency is measured in milliseconds (msec)
○ Most commonly used in evaluating carpal tunnel
syndrome
• Velocity measured in meters per second (m/sec)
○ Most commonly used in evaluating cubital tunnel
syndrome
• 10+ m/sec decrease in velocity at elbow is clinically sig-
nificant; ulnar motor CV <40 m/sec unlikely to respond to
nonoperative management
• Electromyography: useful for diagnosis of denervation
and myopathies
– Brachial plexus injury features
• Loss of motor function (motor neuron cell bodies in ven-
tral horn of spinal cord) with preservation of sensory

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 Hand and Peripheral Nerve 115

function (i.e., demonstrated on nerve conduction stud-

ies) indicates preganglionic nerve root injury (maintained
connection from sensory nerves to dorsal root ganglion)
• Loss of both motor and sensory function indicates post-
ganglionic injury
iv. Repair
– Primary: within hours of injury
• Delayed primary: 5–7 days after injury
– Secondary: more than 1 week after injury
• Primary repair preferred if can be done under appropriate
conditions, but delay is appropriate if initial conditions
are not favorable
• If unable to definitively repair, suture together or tag
nerve ends to prevent retraction
– For blunt injury, a period of observation is appropriate, par-
ticularly in children, who heal better than adults
– Techniques
• Epineurial suture
○ Generally preferred
○ Digital nerve repair is with two to four sutures of
10–0 nylon
• Group fascicular suture
• Individual fascicular suture: rarely indicated as leads to
excess scarring
– Nerve grafting: sural nerve gold standard for donor
– Conduits: vein, collagen, polyglycolic acid all acceptable for
small caliber nerve (i.e., digital nerve) surgery for gaps <3 cm.
Collagen may be superior to polyglycolic acid conduits
– Tendon transfers: when motor endplates not deemed viable
(>1 year following nerve injury w/o evidence of motor recovery)
– Peripheral nerve transfers: expanding role for “babysitting”
motor end plates until injured nerve regenerates. Useful for
proximal ulnar nerve injuries with lengthy distance to motor
endplates (i.e., AIN to ulnar motor transfer; end to side may
be “enough”)
b. Compression neuropathies
i. Median nerve
– Carpal tunnel syndrome: most common compression neu-
ropathy of upper extremity
• Clinical: pain, paresthesias in thumb/index finger/long
finger/radial ½ of ring finger, may be worse at night
– Pronator syndrome: mixed sensory and motor deficit from
compression by pronator teres
• Clinical
○ Sensory: pain, paresthesias along radial side of palm
and thumb, IF, LF, and radial ½ of RF

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 116 Hand and Peripheral Nerve

• Frequently tender over proximal forearm and pronator teres

○ Motor: both intrinsic and extrinsic (FPL; FDP 1,2; PQ)
median-innervated muscles may be affected
– Anterior interosseous syndrome: pure motor deficit from
compression by pronator teres
• FPL and IF FDP most commonly affected, demonstrated in
pinch; IF DIP extends with compensatory
○ PIP flexion while thumb IP hyperextends
ii. Ulnar nerve
– Cubital tunnel syndrome: symptoms may be exacerbated
with elbow flexion, may be related to subluxation of the
ulnar nerve
○ Sensory: numbness along SF, ulnar ½ of RF (may have
Tinel’s sign over cubital tunnel)
○ Motor (variable): intrinsic and grip weakness
iii. Radial nerve
– Posterior interosseous nerve palsy: compression occurs
after bifurcation just proximal to elbow
• Pain, but no sensory changes
• Motor: weakness of finger/wrist extension, may have
radial drift of hand with wrist extension
– Posterior interosseous nerve syndrome (at arcade of Frohse/
supinator muscle fascia)
• Most common; usually a pain syndrome w/o motor involve-
ment and with negative electrodiagnostic studies
– Wartenberg’s syndrome (between brachioradialis and
ECRL): handcuff injuries; direct injury in stick sports
(lacrosse/hockey)
– Vascular leash of Henry (radial recurrent vessels at elbow)
iv. Compartment syndrome
– Compression of the contents of closed compartments
such as the forearm; may lead to irreversible ischemia and
Volkmann’s ischemic contracture
– Diagnosis: clinical examination (pain on passive stretch) or
measured compartment pressures (Stryker needle)
– Treatment: urgent fasciotomy for decompression
c. Tendon transfers
i. Principles and factors in selection
– Strength: will lose one grade of power
• Correlates with muscle volume (cross-sectional area ×
length)
– Excursion
• Correlates with length (of muscle, not tendon)
• Wrist flexors/extensors: 30 mm (insufficient for fingers,
see below)
• Finger extensors: 50 mm
• Finger flexors: 70 mm

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 Hand and Peripheral Nerve 117

– Straight line of pull

– Synergism (+/−): controversial
– Expendable donor
– Tissue equilibrium
– Lack of sensation may limit utility of transfers. Consider
nerve repair/grafting, nerve decompression, nerve trans-
fers, or neurovascular island flaps
– One tendon: one function
ii. Specific lesions
– Median nerve
• Low median nerve palsy
○ Most significant loss is thumb opposition (AbPB; OP;
sup. head of FPB—var. uln. innervation)
○ Opponensplasty candidates
• EIP (most common)
• PL (Camitz): most often used in elderly, low-demand
patients for chronic carpal tunnel syndrome (simultane-
ously as carpal tunnel release)
• FDS IV
• AbDM (Huber): classically used in congenital hypoplastic
thumb
○ Advantage: provides bulk for thenar eminence
○ Disadvantage: insufficient tendon for thumb MCPJ
reconstruction (FDS IV or V better for that)
• High median nerve palsy
○ Deficits in addition to lack of thumb opposition
• Inability to flex thumb IPJ (FPL deficit)
○ Usually addressed with brachioradialis transfer
• Inability to flex index and long finger (FDS, FDP deficit)
○ Usually addressed with side-to-side IF/LF FDP to RF/SF
FDP tenodesis
– Ulnar nerve
• Low ulnar nerve palsy (distal to innervation of LF, SF FDP)
○ Claw fingers of RF, SF (Duchenne sign) result from loss
of lumbricals (which flex MCPJ while extending PIPJ)
• Diagnosis
○ Bouvier maneuver refers to blocking MCP joint hyper-
extension to allow for full PIP/DIP extension
○ Wartenberg’s sign refers to inability to adduct an
extended SF due to unopposed action of EDQ (loss of
interosseous muscle)
• Tx
○ Static tendon transfer: tenodesis of lateral bands with
tendon graft around deep transverse metacarpal liga-
ments to internally splint and prevent hyperextension
of MCPJ
○ Dynamic tendon transfer

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 118 Hand and Peripheral Nerve

• Zancolli lasso: loop FDS around A1 pulley and suture back

to itself to achieve MCP joint flexion
• Bunnell-Stiles transfer: divide ECRL distally, and route it
dorsally. Then two slips of PL (or plantaris graft exten-
sion) are sewn to ECRL. The tendon complex rerouted
through lumbrical canal volar to deep transverse meta-
carpal ligament. Tails of graft attached to radial lateral
bands of RF, SF (or to radial side of P1). Swan neck defor-
mity may result from transfer to radial lateral bands
○ Loss of thumb adduction results from loss of adductor
pollicis
• Dx
○ Froment’s sign refers to thumb IP joint flexion (80–90°)
due to ulnar lesion, resulting from loss of adductor pol-
licis and first volar and second dorsal interossei. FPL
takes over their function.
○ Jeanne’s sign refers to thumb MCP joint hyperextension
during key pinch or gross grip due to ulnar lesion, result-
ing from loss of adductor pollicis (adducts first meta-
carpal, flexes thumb MCPJ, and extends thumb IPJ)
• Tx
○ ECRB to thumb adductor via intercalated tendon graft
○ MF or RF FDS to thumb adductor insertion
• High ulnar nerve palsy (proximal to innervation of LF, SF
FDP)
○ Same deficits as with low palsy, but also lose RF and
SF FDP
○ Clawing also occurs, but not as severe as FDP is also
lost (ulnar paradox), and no longer flexes DIPJ
– Combined median and ulnar nerve palsy
• Most often low median-ulnar lesion due to wrist laceration
• Clawing in IF, LF, RF, and SF due to loss of all lumbrical
innervation
• Goals include improvement of: key pinch, thumb abduc-
tion (to assist opposition), tip pinch (loss of first dorsal
IO), power finger flexion with coordinated MP and PIP
motion, and sensibility in key pinch distribution
• Tx options
○ Thumb opposition
• EIP transfer
• Alternate: PL or FDS
○ Thumb adduction
• ECRB
• Long finger FDS
○ Thumb-index key pinch
• Thumb IP fusion
• Transfer of APL with graft extension to first dorsal IO

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 Hand and Peripheral Nerve 119

– Radial nerve palsy

• Most significant deficit is lack of wrist extension (stabi-
lizes wrist and increases grip strength up to 5x)
○ Note that all the below schema include PT → ECRB to
achieve wrist extension
○ MCPJ extension is more variable, transferring to EDC:
FCR, FCU, or FDS III
• FDS III is chosen as it has a separate muscle belly, and
won’t affect remainder of FDS
○ To be used, it must be passed to EDC through a window
in interosseous membrane
• Several authors have recommended preserving FCU (avoids
wrist radial deformity and unnecessary wrist flexion weak-
ness) with the following:
○ PT → ECRB
○ FCR → EDC
○ PL → EPL
• Alternative approach when PL not available
○ PT → ECRB + ECRL
○ FCR → APL + EPB
○ FDS (IV) → EPL + EIP
○ FDS (III) → EDC
• An FCR-sparing approach
○ PT → ECRB + ECRL (rerouted)
○ FCU → EDC + EIP
○ PL → EPL
• Other
○ PT → ECRB + ECRL (rerouted)
○ FDS (IV) → ECD (II, III, IV, V)
○ FCR → EPL + EIP
○ PL → APL + EPB

G. SOFT TISSUE RECONSTRUCTION

1. Fingertip
a. Deficits <1.5–2 cm2 (w/o exposed bone) can be allowed to heal by
secondary intention
b. Homodigital advancement flaps: preserve neurovascular pedicle for
sensation and perfusion
i. Volar V-Y (Atasoy): best for transverse/oblique tissue loss of
volar pulp
ii. Bilateral (radial + ulnar) V-Y (Kutler)
iii. Reversed digital artery island
iv. Hueston transposition
v. Moberg: reserved for thumb due to unique arterial pattern (up
to 1.5 cm can be covered)

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 120 Hand and Peripheral Nerve

c. Heterodigital flaps: require inset + division (two operations), may

result in stiffness; relatively poor sensibility
i. Cross-finger: uses tissue from dorsal middle phalanx of adja-
cent finger; cover donor site w/ skin graft
ii. Thenar: pedicle based on soft tissue of thenar eminence
iii. Neurovascular island
d. Skin graft: allows for sensation, more rapid rehab than heterodigital
flaps
i. Full-thickness skin (can use “spare parts” if mutilated hand)
graft recovers sensation better than split-thickness skin grafts
ii. Not appropriate for exposed bone or directly over neurovascular
bundle
e. Small defects of hand/digits
i. Homodigital flaps
– Adipofascial
ii. Heterodigital flaps
– Venous flaps
– Dorsal metacarpal artery flap
iii. Regional
– Flag flap
– Dorsal metacarpal artery flaps: useful for dorsal hand and
proximal finger coverage
– Reverse dorsal metacarpal artery flap: useful for distal dor-
sal finger coverage
f. Large defects of hand/digits
i. Regional flaps
– Reverse radial forearm flap: excellent choice for dorsal hand
(soft, compliant, thin)
• Multiple digital defects may be repaired with a single flap and
release of syndactylies may be performed at a second stage
• Disadvantages include donor site and sacrifice of radial
artery
– Ulnar artery island flap
– Posterior interosseous artery flap (vessel dissection can be
tedious)
ii. Distant flaps
– Pedicled flaps: disadvantage = requires inset and division
(two surgeries), may lead to stiffness
• Groin flap: not a sensate flap, therefore not ideal for
thumb or other areas requiring sensation
○ Based on superficial circumflex iliac artery (SCIA) or
superficial inferior epigastric artery (SIEA)
– Free flaps (many options)
• First web-space flap: good source of sensate, glabrous
skin

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 Hand and Peripheral Nerve 121

• Harvested from lateral great toe and medial second toe

(~3 cm long x 6 cm wide), based on first dorsal metatar-
sal artery (less often, first volar metatarsal artery); can
dissect up to dorsalis pedis if additional length required.
Generally harvested with saphenous vein system
• Donor site may be covered with split-thickness skin graft
(STSG)

H. CONGENITAL
1. Embryology
a. Limb bud differentiates between weeks 3 and 8
b. Three critical regions for differentiation
i. Apical ectodermal ridge (AER): controls mesodermal differen-
tiation, governs proximal to distal growth
– Secretes fibroblast growth factor. Disturbance may result in
conditions such as transverse arrest and syndactyly
– Dorsal ectoderm: controls dorsal to palmar differentiation
via dorsalizing factor Wnt-A
– Zone of polarizing activity (ZPA): controls anterior to pos-
terior development, regulated in part by secretion of sonic
hedgehog (Shh) protein secreted by posterior part of limb;
disturbance may result in condition such as ulnar dimelia
2. Classifi cation (Swanson) (Swanson AB, Swanson GD, Tada K, J Hand
Surg Am. 1983 Sep;8(5 Pt 2):693–702)
a. Failure of formation (I)
i. Transverse arrest
– Most commonly occurs just below elbow to upper 1/3 of
forearm
– Phocomelia: condition in which limb is abnormally short
• Complete: hand attached directly to trunk
• Proximal: proximal segment missing, forearm attached to
trunk
• Distal: hand attached to arm
– Robert syndrome: tetraphocomelia (similar to thalidomide
embryopathy) + CNS and craniofacial anomalies
ii. Longitudinal arrest
– Radial
• Radius
○ Classification
■ Type I: short distal radius
■ Type II: hypoplastic radius
■ Type III: partial absence of radius
■ Type IV: complete absence of radius
○ Treatment
■ First, evaluate for VACTERL, TAR syndrome, Fanconi
anemia, Holt-Oram, etc.

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 122 Hand and Peripheral Nerve
■Surgery considered if lack of radial support for hand,
if have thumb/finger deformities, or radial contrac-
tures resistant to stretching
■ Multiple stages
□ Distraction: to recruit soft tissues
□ Centralization: performed after 6 months of age
□ Thumb reconstruction
■ Contraindications to surgery include adequate func-
tion, life-threatening conditions, or those in which
the present radial deviation is necessary to get the
hand to the face
– Madelung deformity (distal radial growth disturbance at the
volar epiphyseal plate)
• Thumb hypoplasia
○ Blauth classification (modified by Manske and McCarroll)
■ Type 1: minor generalized hypoplasia
■ Type 2: absence or hypoplastic intrinsic thenar mus-
cles with narrow first web and collateral ligament
insufficiency
■ Type 3: same as type 2, but also with extrinsic mus-
cle/tendon abnormality with skeletal deficiency
□ 3A: stable carpometacarpal joint
□ 3B: unstable carpometacarpal joint
■ Type 4: floating thumb (pouce flottant)
■ Type 5: absence of thumb
○ Treatment
■ Type 1: surgery not indicated
■ Types 2, 3A: thumb web space deepening, opponens
transfer, UCL reconstruction
■ Types 3B, 4, and 5: pollicization (toe-to-thumb
transfer results are poorer than pollicization)
– Central deficiency (cleft hand)
• Typical (lobster claw deformity)
○ V-shaped, autosomal dominant, syndactyly, no fin-
ger nubbins, one to four limbs affected, small finger
preserved
• Atypical (symbrachydactyly)
○ U-shaped, sporadic, finger nubbins, usually only one
limb (upper) affected, thumb preserved
– Ulnar deficiency
• Much less common than radial deficiency
• Tend to be strictly skeletal anomalies w/o other lesions
associated with radial deficiency
• Treatment focuses on obtaining functional thumb-index
web space

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 Hand and Peripheral Nerve 123

b. Failure of differentiation/separation of parts (II)

i. Carpal coalition
– Most often affect lunate and triquetrum
– Most common in those of West African descent; familial
association and commonly bilateral
ii. Arthrogryposis
– Generalized contracture in limbs
– Characteristic upper extremity pattern
• Shoulder: adducted, internally rotated
• Elbow: extended
• Forearm: pronated
• Wrist: flexed, ulnarly deviated
• Thumb: flexed, adducted
• Fingers: MCPJ flexed, ulnarly deviated
– Treatment
• Early in life: manipulation, splinting
• Later: surgery undertaken to release contractures, place
extremities in functional positions, or move functional
muscles
iii. Poland’s syndrome (Alfred Poland described 1849)
– 1/30,000 live births, M:F is 3:1, most often on right side
– Absence of sternal head of pectoralis muscle
– May also include: hypoplastic hand; brachysyndactyly; absence
of ribs 2–4; hypoplasia of breast and nipple areolar complex
(NAC); hypoplasia of shoulder muscles (including latissimus
dorsi); short forearm bones; deficiency of subcutaneous fat;
absence of axillary hair
– Treatment
• Reconstruction is performed in adolescence using either
latissimus dorsi muscle flap (male) or tissue expanders/
implants (female)
iv. Syndactyly (web space fusions due to failure of apoptosis)
– 1:2000 live births in US. Caucasians > blacks. Usually long,
ring finger. M>F (2:1). AD inheritance with variable pene-
trance. Usually isolated, nonsyndromic, but may be associated
with the following:
• Apert, Pfeiffer, Carpenter, Holt-Oram syndromes; trisomy 21
• May also involve the toes (most common between great
and second toes)
– Anatomy
• Thickened Cleland’s, Grayson’s ligaments, and web space
palmar fascia
• Structures usually duplicated normally (exception: abnor-
mal tendons with Apert syndrome)
– Classification
• Simple (cutaneous): no bony fusion
○ Operative principles

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 124 Hand and Peripheral Nerve

• Make volar Brunner incision needed, using dorsal and

volar flaps for the web space, and full-thickness grafts
for the remainder, with eponychial flaps as needed
• Complex (osseous): bony fusion present
• Complicated: polydactyly present
• Complete: syndactyly extends to tips of fingers
• Acrosyndactyly: associated with constriction ring syn-
drome (Streeter syndrome)
– Surgery
• Pre-op
○ Workup: X-rays to r/o complex syndactyly
○ Timing
• Usually 12–18 months
• By 4–6 months for complex syndactyly involving border dig-
its or if discrepant finger length may lead to abnormal growth
• Procedure
○ Simple syndactyly
• Create dorsal and volar flaps with zigzag incisions to rec-
reate web space
• Cover any skin deficits with full-thickness skin grafts
• First web-space lengthening: butterfly/jumping man flap,
single Z-plasty (75% increase), four flap Z-plasty (164%
increase)
v. Camptodactyly
– Congenital flexion contracture of PIP joint, usually sporadic
and occurs most often in small finger
– Two forms occur: infancy-onset and adolescence-onset
– Mechanical etiology multifactorial: intrinsic-minus defor-
mity from abnormal insertion of lumbrical; FDS IV and FDS
V adherence; other
– Radiographic findings: narrow PIP joint space, P2 volar
indentation (+/−), flattening of volar and dorsal surfaces
of P1 condyles, widened base of P2
– Treatment: conservative approach with stretching or surgi-
cal release or all structures preserving tendon and neuro-
vascular bundles
vi. Clinodactyly
– Abnormal radial-ulnar angulation of digits from phalangeal
dystrophy
– Sometimes associated with delta phalanx (abnormally
shaped phalanx due to bracketed epiphysis); increased inci-
dence in trisomy 21
– Commonly manifests as radial deviation of small finger at
DIP joint
– Rarely a functional limitation; surgery requires corrective
osteotomy
vii. Vascular anomalies (see chapter on cutaneous disease, p. 159)

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 Hand and Peripheral Nerve 125

c. Duplication (III) (most common class of congenital hand anomalies,

5–10/1000 live births)
i. Mirror hand (ulnar dimelia)
– Two ulnae, no radius, seven to eight fingers, no thumb, short
arm with thick wrist and elbow
– Frequently have problems with elbow, forearm, and wrist
mobility
– Surgery is staged to address problems in following order:
elbow mobility, forearm mobility, wrist stability, hand
ii. Polydactyly
– Preaxial (thumb) duplication more common in Caucasian,
Asian children
• Wassel classification most commonly used
○ I: bifid distal phalanx
■ Treat with excision of smaller part or Bilhaut-
Cloquet closure
○ II: completely duplicated distal phalanx
■ Treat as Wassel I
○ III: bifid proximal phalanx
■ Treat with removal of smaller duplication (usually
radial) + reconstruction of radial collateral ligament
and osteotomy
○ IV: completely duplicated proximal phalanx (most
common)
■ Treat as Wassel III
○ V: bifid metacarpal; rare
■ Requires exploration/rebalancing of intrinsic/extrinsic
muscles +/– web space widening
○ VI: completely duplicated metacarpa; rare
■ Treat as Wassel V
○ VII: triphalangeal thumb (delta phalanx)
■ Unlike other thumb duplications, associated with vis-
ceral anomalies (Holt-Oram, Fanconi anemia, Diamond-
Blackfan anemia, Juberg-Hayward, PDA, ASD, VSD)
■ If very young, excise accessory phalanx; later,
combined longitudinal and transverse osteotomies
required
– Post axial duplication more common in African American,
Native American children (Note: duplication overall is much
more common in blacks than whites or Asians)
• Classification (Simmons BP, Hand Clin. 1985 Aug;1(3):
545–65)
○ Type 1: soft tissue nubbin with skin bridge (can be
addressed with clipping or tying off in nursery; but this
may leave a prominent scar and/or neuroma)

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 126 Hand and Peripheral Nerve
○ Type 2: Type I + bone involvement
○ Type 3: complete duplication of entire digit
– Central polydactyly
• <10% of duplications
• Usually bilateral
• Often associated with AD inheritance
d. Overgrowth (IV)
i. Hemihypertrophy
– Associated with vascular anomaly (see chapter on cutaneous
disease, p. 159)
ii. Macrodactyly: one of the least common hand anomalies
– True cases involve all structures, most commonly radial digits
– Classification (Dell) by association with other congenital
neoplasms
• Type I: associated with lipofibromatous hamartoma of
involved nerve (usually median or ulnar n.)
• Type II: associated with neurofibromatosis
• Type III: associated with polyostotic fibrous dysplasia,
most rare
• Type IV: not part of original Dell classification; unilateral,
associated with hemihypertrophy (proteus syndrome,
Klippel-Trenaunay syndrome); hand components do not
become as large as with previous three types
– Treatment
• Types I, II, III: bulk reduction in infancy, then later as needed
○ Perform epiphyseal arrest at proximal end of phalan-
ges when external length matches parental hand
• Amputation indicated for anesthetic digit, stiffness of
single digit, or when digit impairs function significantly
• Type IV: results generally poor; consider operating for
joint restrictions or hand deformities
e. Undergrowth (V)
i. Brachydactyly
– Most often affects radial border of hand; often associated
with syndromes/systemic disorders
– Classification
• Type A: shortening confined to P2
• Type B: shortening (or absence) of P2 and P3; deformity of
pollex and hallux as well
• Type C: deformity of P1, P2 of IF, LF with ulnar deviation;
AD inheritance
• Type D: short, broad P2 of pollux and hallux
• Type E: shortening involves one or more metacarpals
– Treatment: surgical lengthening usually not indicated,
although use of distraction osteogenesis reported
• Other options include: nonvascularized toe-phalanx trans-
fer, microsurgical toe transfer

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 Hand and Peripheral Nerve 127

ii. Symbrachydactyly (short, webbed fingers; place in classification

schema controversial)
– Absent mesoderm, characterizing finger “nubbins,” which are
ectodermal remnants
– Ranges from short fingers to transverse arrest proximal to
wrist with nubbins
– Associated with Poland’s syndrome
– Tx: toe-to-hand transfers can be successfully used to
restore pinch
f. Congenital constriction band syndrome (VI)
i. Generally narrow areas of constriction in skin/subcutaneous
tissue, most often affecting inner, longer fingers
ii. Distal ischemia, lymphedema, or secondary acrosyndactyly may
occur. Rare, more extensive effects include tendon division or
amputation. 80% associated with other hand deformities, and
up to 50% associated with anomalies outside the hand (cleft
lip/palate, club foot, cardiac anomalies, meningomyelocele,
hemangioma, etc.).
iii. Etiology/epidemiology
– Incidence 1:15,000; occurs in sporadic fashion, associated
with oligohydramnios and prematurity
– Results from inner layer of chorionic sac detaching and
wrapping around part of the fetus
iv. Classification (Patterson)
– Type I: simple constriction rings
– Type II: rings + deformity of distal part +/– lymphedema
– Type III: rings + fusion of distal parts (mild-to-severe
acrosyndactyly)
– Type IV: intrauterine amputations
v. Tx: excision of constricted band with layered closure and/or
Z-plasty; urgently perform if neurovascular compromise
– Type III may require syndactyly releases
g. Generalized syndromes (VII)
i. Associated with craniosynostosis
– Apert
– Pfeiffer
ii. Associated with radial deficiency
– Holt-Oram syndrome (AD)
• May have radial club hand, thumb absence/hypoplasia/
triphalangism, or less impressive preaxial carpal anomalies
iii. Associated with cardiac defects (ASD, VSD, conduction blocks/
abnormalities, etc.)
– Fanconi anemia (AR)
• Radial limb abnormalities may include absent radii or
hypoplastic thumbs (usually more severe distally)
• Progressive bone marrow failure develops up to 6–8 years
after birth; pancytopenia limits life expectancy to <30 years

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 128 Hand and Peripheral Nerve

• Other findings may include café au lait spots, microceph-

aly, genital anomalies, and short stature
• Diagnosed with fragile chromosome test
• Early diagnosis may improve prognosis by allowing for
bone marrow transplant
– TAR syndrome
• Absent or hypoplastic radii; thumbs present, but may be
hypoplastic
• Thrombocytopenia (not pancytopenia) presents within
four months of birth
• Much better prognosis than Fanconi anemia
– VACTERL
• Vertebral, anal, cardiac, tracheoesophageal (fistula),
renal/radial limb defects
– Treacher Collins syndrome
• Mandibulofacial dysostosis
v. Other
– Congenital trigger thumb: ~1:2500 births, presents as
flexed digit in first 3 years of life
• Diagnosis: differentiate from camptodactyly (PIP con-
tracture, usually in small finger)
• Treatment: surgical release recommended if not resolved
by 1 year of age (30% of cases spontaneously resolve)
– Achondroplasia
– Dyschondroplasia
– Dystrophic dwarfism
– Marfan syndrome

I. OTHER
1. Tourniquet and Esmarch
a. After prepping extremity, wrap upper arm with three rolls of Webril,
then place tourniquet over Webril only with two valves pointing out
of field toward machine. Wrap 1000 drape circumferentially with
adhesive over skin as well as distal edge of cuff with drape oriented
proximally. Wrap Esmarch from fingers to tourniquet, then inflate tour-
niquet to 50–75 mm Hg above patients systolic pressure; 250 mm
b. Hg is standard (may be higher for obese, atherosclerotic patients,
etc.). Can preset tourniquet to this pressure and time to alarm
(i.e., set at 90 min if desire no more than 2 hours ischemia). Two
hours is time limit to avoid muscle and nerve injury. For prolonged
operations, the tourniquet should be released 5 minutes for every
30 minutes of use. If suspected malignant or infectious lesion in
the extremity, do NOT use Esmarch to exsanguinate; rather, elevate
the extremity and compress brachial artery for 1 minute

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 4 ■ BREAST

A. ANATOMY
1. Perfusion: superficial collateral flow from second/third interspace IMA
perforator; additional deep flow predominantly from IMA perforator at
fifth/sixth interspace
2. Innervation: majority of sensation to nipple-areolar complex (NAC)
from lateral branch of the fourth intercostal nerve

B. RECONSTRUCTION
1. Goals: restore components of breast after complete or partial
mastectomy
2. Considerations: timing (immediate, delayed), patient habitus and
prior surgery, adjuvant therapy (XRT, chemo)
3. Immediate versus delayed
a. Immediate
i. Advantages
– Superior result particularly with autologous (no patch
effect)
– No scar tissue to complicate reconstruction
– Reduced anesthetic risk
– Reduced costs
– Improved immediate body image
ii. Disadvantages
– Decision made at time of stress
– Increased risk of complications (infection, implant expo-
sure, mastectomy flap necrosis)
b. Delayed
i. Advantages
– Patient has time to consider alternatives
– Avoids reconstruction complication potentially delaying
chemotherapy
ii. Disadvantages
– Adjustment period of dealing with loss of breast then
accepting breast as own
4. Autologous versus prosthesis-based
a. Autologous: use of woman’s own tissue (skin, muscle, fat) from
another part of the body (flap reconstruction)
i. Advantages
– May eliminate use of foreign material
– Usually looks and feels more natural

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 130 Breast

– Lifelong reconstruction
– If successful, minimal additional surgeries
ii. Disadvantages
– Increased complexity and length of surgery
– Longer recovery
– Risk of donor site complication
– Smokers, women with vascular or connective tissue dis-
eases, and diabetes are at increased risk of wound-healing
complications
– Some women may also require an implant for adequate
volume
iii. Adjuvant therapy
– Irradiation (XRT)
• Conservative therapy encompasses wide localized exci-
sion (WLE), axillary lymph node dissection (ALND), and
irradiation postmastectomy radiation therapy (PMRT)
• Considered when risk of local recurrence >20%
○ >three axillary lymph nodes
○ Tumor size >4 cm
○ T4 disease and close/+ margin
iv. Autologous reconstruction preferred after healed from XRT
– Transverse rectus abdominis myocutaneous (TRAM)/deep
inferior epigastric perforator (DIEP) flap
– Latissimus dorsi (LD) flap
v. Tissue expander reconstruction less ideal
– XRT after completion of expansion if possible
– Avoid expanding radiated skin
– XRT increases complications (infection, capsular contrac-
ture, implant exposure)
vi. Chemotherapy
– Surgical timing
• Wait at least 1 month for any staged procedure
○ Allows immune system recover
• Check CBC (r/o leukopenia, anemia, thrombocytopenia)
– Herceptin: cardiotoxic, consider cardiology consult
vii. Autologous options
– Pedicled flaps
– LD flap
* Note: With the unusual exception of the extended latissimus flap, this option
almost always requires prosthesis for volume.
• Most often reserved for patient with unsuitable skin for
implant alone (e.g., post-XRT)
• Blood supply thoracodorsal artery (1–2 mm diameter)
• If thoracodorsal artery severed LD flap is supplied by ser-
ratus branch via intercostal arteries/collateral vessels
• Flap width: average 7 cm, may be up to 12 cm depending
on body habitus

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 Breast 131

• Flap length: 14–16 cm to 25–30 cm

• Skin island can extend 5–7 cm beyond anterior/posterior
border w/o vascular compromise
• Within 6–12 months 50% muscle atrophy occurs (muscle
sparing LD flap also option)
– TRAM flap
• Blood supply superior epigastric artery
• Zone I good circulation; contralateral zone IV watershed
• To optimize blood supply supercharge: deep inferior ves-
sels (leave long) anastomosed to thoracodorsal vessels
• If preoperative concern perform delay: deep inferior ves-
sels ligated 1–2 weeks before TRAM procedure
• Mesh used to prevent hernia formation
viii. Free flap
– Abdominal tissue
• Free TRAM flap
○ Blood supply: deep inferior epigastric vessels
○ MS-0: sacrifice of full width of rectus muscle
○ MS-1: preservation of the lateral segment of rectus
muscle
○ MS-2: medial and lateral rectus muscle preserved;
medial and lateral perforators incorporated
• DIEP flap: microvascular transplant of abdominal flap
composed only of fat and skin (muscle sparing)
• Superficial inferior epigastric perforator (SIEP) flap
○ Avoids all muscular dissection
○ Least amount of abdominal wall morbidity
– Buttock tissue
• Inferior gluteal artery perforator (IGAP), or in-the-crease,
flap
• Superior gluteal artery perforator (SGAP) flap
– Thigh tissue
• Transverse myocutaneous gracilis (TMG) flap
○ Inconspicuous donor site scar within groin crease
○ Invariable vascular anatomy
○ Closure of donor site can be facilitated simultaneously
as flap anastomosis
○ Limited volume available
– Free flap challenges
• Risk of total failure ~5%
• Additional venous anastomosis may be required if flap
congestion
○ Cephalic
○ Internal mammary vein
○ Thoracodorsal vein
• Mastectomy flap necrosis
○ May require skin grafting

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 132 Breast

5. Nipple and areolar reconstruction

a. Nipple grafting from contralateral breast
i. If sufficient projection, horizontal cut
ii. Best option for natural appearance
b. Local flaps
i. C-V flap
ii. Skate flap
iii. Star flap
c. Full-thickness skin grafting
i. Donor sites: groin, labia minora
d. Filler injections: good option for correcting loss of projection
e. Timing for nipple reconstruction, areolar tattoo: after the shape and
volume is satisfactory
i. Tattoo ~2 months after nipple reconstruction to minimize risk
of nipple necrosis

C. REDUCTION MAMMOPLASTY
1. Indications: many insurance companies identify criteria such as 500 g
excess mass per breast, bra strap notching, or inframammary fold
(IMF) rashes for reimbursement
2. Average measurements
a. Sternal notch-to-nipple distance: 21–23 cm
b. Nipple-to-IMF distance: 5–7 cm
c. Nipple-to-sternal distance: 9–11 cm
3. Risk factors for need for free nipple graft: nipple to IMF 18 cm,
sternal notch to nipple 30 cm
4. Risks
a. Diminished NAC sensation: lateral cutaneous branch of fourth
intercostal nerve; nerve runs along pectoralis fascia (preserve fat
layer above)
b. NAC necrosis
i. Usually noticed within 48 hours postoperatively, but may occur
7–10 days later in smoker
ii. If impending necrosis hyperbaric oxygen/leeches may help
– Delay débridement
– Minor loss of areola → tattoo
– Loss of nipple → standard nipple reconstructive technique
– Total loss of nipple-areola
• Increased risk of pedicle loss
○ Fat grafting
○ Autologous reconstruction
c. Effects on breastfeeding
i. 50–70% chance of nursing postoperatively

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 Breast 133

5. Preoperative evaluation and preparation

a. History: onset (recurrence common if juvenile hypertrophy); comor-
bidities include DM, smoking, FHx breast CA, symptoms, desired size
b. Exam: bra size, masses, nipple d/c, skin quality
c. Radiology: recent (1 yr) mammogram if >30 yo
d. Counseling: discuss postop size and scarring with patient—trading
size for scars: 15% have sensation changes; no evidence of change
in lactation with reduction
e. “Normal” distances: sternal notch – N = 21–23 cm, N–IMF= 5–7 cm
f. Marking: circumvertical (parenchyma provides shape), Wise pattern
(skin shapes the breast). Pedicle 6–8 cm wide. If N–IMF >18 cm,
consent for free nipple graft
6. Techniques
a. Skin
i. Wise pattern: traditional, relatively easy to learn, but tendency
to “bottom out” early
ii. Vertical skin pattern: steeper learning curve, but better upper
pole projection
b. Pedicle
i. Superior medial pedicle
– Reliable, adequate sensation, preserves glandular-areolar
attachment, maintains medial and superior fullness
ii. Superior pedicle
– Reliable, superficial blood supply, excellent projection
iii. Lateral pedicle: relatively uncommonly used
iv. Inferior pedicle: historically the most commonly used, increased
risk of “bottoming out”
7. Complications and curve balls
a. Mass found: bx and frozen section. If CA, stop, close, treat.
b. Can’t close incisions: free up pedicle, go smaller, or STSG
c. NAC blue/dusky: nitro paste, open incisions, free nipple. Make sure
BP okay
d. If you have to open, cover w/ dressing and return in 2–3 days when
edema resolves to try and reclose
e. Hematoma: OR drainage
f. Asymmetry: reduce larger side later
g. Redo: get old op report and use that technique; if unknown, don’t
do, free nipple graft, or lipo + skin resection
h. NAC malposition (err on low side as it is easier to fix!!!)
– Low = crescent excision superiorly
– High = shorten vertical limb, wedge incision inferiorly; if
substantially high, consider tissue expansion to lower NAC
8. Mastopexy
a. Breast ptosis
i. Regnault grading
– Pseudoptosis: gland inferior to IMF, but nipple superior to IMF
– Grade 1: nipple at or up to 1 cm below IMF

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 134 Breast

– Grade 2: nipple 1–3 cm below IMF, not at point of maximum

dependence
– Grade 3: nipple >3 cm below IMF or at point of maximum
dependence
ii. Techniques
– Minimal required lift (small breasts, mild/moderate ptosis)
may be achieved with periareolar (Benelli) approach
• Augmentation alone may be also adequate for mild ptosis
• Augmentation concurrent with mastopexy can be chal-
lenging, and should be typically reserved for surgeons
with advanced experience
– Otherwise, modifications of conventional reduction mam-
moplasty (vertical incision pattern) procedures used w/o
resecting parenchyma (redistribute, don’t excise)
9. Tuberous breasts
a. Herniation of breast tissue through areola
b. Relative inferomedial hypoplasia
c. Combination of augmentation and periareoloar mastopexy com-
monly performed

D. AUGMENTATION
1. Choice of implant
a. Size: mainly determined by breast width and projection in conjunc-
tion with patient desires
i. Larger implants prone to ptosis more quickly
b. Fill material
i. Silicone: more natural feel, less prone to “wrinkled” appear-
ance in thin women
ii. Saline: may be less expensive, may provide increased upper
pole fullness; main recommendation is for women who fear
silicone implants or silent ruptures
c. Implant shell surface: textured versus smooth surface
i. Advantages
– Smooth surface: less rippling and palpability
– Textured: tissue integration (important for anatomic shaped
implants)
d. Implant shape: anatomic versus round
e. Implant profile: moderate, moderate plus, and high profile (Mentor)
versus low, medium, high, and extra high profile (Allergan)
2. Choice of approach
a. Periareolar
i. IMF (inframammary): most common approach, easy to learn
ii. Axillary/endoscopic: reliable approach with use of endoscope
iii. Transumbilical breast augmentation (TUBA): higher revision
rate and lower satisfaction score

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 Breast 135

3. Choice of placement
a. Subglandular: higher rates of capsular contracture and rippling
b. Submuscular (under pectoralis muscle): dual-plane; partial sub-
muscular (types 1, 2, 3): depends on degree of muscle release from
overlying breast parenchyma
4. Risks
a. Capsular contracture
i. Hyperimmune response to the foreign body (i.e., implant)
resulted in thickening, tightening, or the implant capsule
resulting in various degrees of deformity and possibly pain
ii. Grading of capsular contracture: Baker’s classification (Spear
SL, Baker JL, Jr., Plast Reconstr Surg. 1995 Oct;96(5):1119–23)
– Baker’s 1: soft capsule, appear natural
– Baker’s 2: capsule if firm/hardened, but the breast appears
natural
– Baker’s 3: hard, thickened capsule with distorted-appear-
ing breast
– Baker’s 4: hard capsule with very distorted breast and pos-
sible associated pain
iii. Prevention of capsular contracture: sterile no-touch technique,
placement of implant in submuscular position, triple antibi-
otic solution irrigation (Adams WP Jr, Rios JL, Smith SJ, Plast
Reconstr Surg, 2006;117(1):30–6), and occlusive dressing over
the nipple
iv. Treatment of capsular contracture
– Medical: accolate, singulair, flector patch—possible treat-
ment options, but no proven benefit; all anecdotal
– Surgical: complete capsulectomy with placement of a new
implant in the submuscular position
b. Hematoma: should be surgically addressed with complete evacua-
tion of clot, consider pulse lavage to minimize secondary capsular
contracture
c. Infection
i. Prevention: single dose of IV cefazolin or vancomycin prior to
surgery, no-touch technique, triple antibiotic solution
ii. Tx: cellulitis—trial of oral, then IV abx. If fails, explantation,
wait 3 months, and repeat augmentation; implant salvage
has been described (Spear SL, et al., Plast Reconstr Surg,
2004;113(6):1634–44)

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36364_CH04_129-[Link] 136 1/3/13 7:36 PM
 5 ■ TORSO AND PRESSURE ULCERS

A. CHEST WALL RECONSTRUCTION

1. Indications
a. Instability defined by discontinuity of 4+ adjacent ribs or defects
>5 cm
b. Defect >5cm
2. Options
a. Marlex +/− methyl methacrylate, ePTFE, other options for stability
to avoid paradoxical motion
b. Regional flaps to provide durable coverage and reduce dead space
i. Pectoralis advancement (based on thoracoacromial a.)
ii. Pectoralis turnover (based on internal mammary a. (IMA)
perforators)
iii. Latissimus (based on thoracodorsal a.)
iv. Rectus abdominus (based on superior epigastric a.)
v. Omentum (based on right gastroepiploic a.)
3. Sternotomy infections
a. Pairolero classification (Pairolero PC, Arnold PG, Ann Thorac Surg,
1986;42;1–2)
i. Type I: serosanguinous drainage within first 72 hours with no
overt sx infection (neg. cx, neg. osteomyelitis, etc.) → explore,
débride, close
ii. Anything beyond this (Pairolero type 2,3) → removal of any
hardware, liberal débridement of devitalized bone and soft tis-
sue, flap coverage
iii. Pectoralis advancement, pectoralis turnover, rectus abdominus
(if IMA not harvested for CABG), omentum, etc.
4. Abdominal wall (Rohrich RJ, et al., Plast Reconstr Surg, 2000;
105(1):202–16; Jernigan TW, et al., Ann Surg, 2003;238(2):349–55)
a. Components separation (Ramirez OM, et al., Plast Reconstr Surg,
1990;86(3):519–26)
i. Can gain up to 20 cm advancement at umbilicus, 10 cm in epi-
gastrium, 6 cm in suprapubic region
ii. Divides medial border of external oblique fascia and medial/
posterior aspect of posterior rectus sheath
b. Mesh/acellular dermis
c. Acutely ill patients in ICU: optimize nutrition, control enterocutaneous
(EC) fistulas, can place negative pressure wound therapy device
(e.g., VAC), Vicryl mesh, allow to granulate then skin graft; return
later to replace with definitive coverage

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 138 Torso and Pressure Ulcers

d. Tissue expanders for superficial coverage

e. Flaps (pedicled): rectus abdominis, tensor fascia lata (TFL), rectus
femoris, anterolateral thigh (ALT), groin, latissimus dorsi (LD)
f. Flaps (free): LD, ALT, TFL
5. Perineum/vagina
a. VRAM
b. Gracilis
c. Fasciocutaneous (Singapore flap)
6. Pressure ulcers
a. Etiology and epidemiology
i. Up to 10% long-term hospitalized patients and 25% paraplegic/
quadriplegic patients develop some stage of these wounds
ii. Only 4% occur above the level of the umbilicus
iii. Capillary blood pressure 12 mm Hg on venous end, 32 mm Hg
on arterial end (Landis EM, Heart, 1930;15:207–28)
iv. Pressure and shearing forces contribute; skin maceration and
colonization contribute to chronicity of wound
b. Staging
i. Stage I: nonblanching erythema, but no skin breakdown
ii. Stage II: partial dermal loss
iii. Stage III: full-thickness dermal loss
iv. Stage IV: through dermis into underlying bone, muscle, or tendon
c. Management principles
i. Do not operate unless medically optimized
– Optimize nutrition (albumin >3.4 ideal), eliminate infec-
tion, reduce spasm (baclofen, lorazepam, rhizotomy, etc.),
+/− release contractures, provide appropriate mattress,
nursing care
ii. Surgery
– Débride after painting wound cavity with methylene blue
to guide process; avoid ostectomy unless necessary (fre-
quently just redistributes pressure for new pattern of
ulcers)
iii. Minimize bridge-burning: V-Y flaps, posterior thigh flaps popu-
lar as can often be readvanced
iv. Postoperative long-term use of drains and proper positioning
important
v. Specialty mattress (low air loss, Clinitron), customized wheel-
chair cushions can diminish recurrence
d. By site
i. Ischial: most common (28%)
– Inferior gluteal myocutaneous flap, posterior thigh advance-
ment flap, biceps femoris flap, gracilis
ii. Sacral: gluteal fasciocutaneous (musculocutaneous if deep
defect), transverse lumbar (lumbosacral) flap
iii. Trochanteric: tensor fascia lata +/− Girdlestone procedure

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 Torso and Pressure Ulcers 139

B. AESTHETIC
1. Massive weight loss patients
a. Metabolic workup
i. Weight loss surgery at least 12 months prior, weight stable for
3–6 months
ii. Check iron, folate, B12, albumin, and prealbumin
b. High risk for wound complications and thromboembolic events:
don’t commit to surgery >6 hours
c. Weigh risks and benefits of heparin SQ prophylaxis
d. Protein supplementation before and after surgery
2. Liposuction
a. Tumescent solution or superwet: most appropriate with 1% blood
loss; wet and dry have much higher rates of blood loss
b. Endpoints: >4 L, bloody aspirate, or satisfied with pinch test
c. Fluid resuscitation: generally 2 × aspirate = tumescent + IVF
d. Cross-tunneling to prevent contour deformities: larger cannulas
more prone to contour deformities
3. Abdominoplasty
a. Full: involves resection of fat/skin, repositioning umbilicus, and
plication of diastasis +/− liposuction
b. Mini: plicates and excises exclusively below umbilicus, can involve
“floating” the umbilicus
c. Fleur-de-Lis: enables surgeon to recruit and excise additional lat-
eral tissue
d. Circumferential: if excess tissue in abdomen, flanks, but hips/
buttocks not sagging
e. Lower body lift: if hips, buttocks sagging, addresses lateral aspect
of hips

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 6 ■ LOWER EXTREMITY

A. TRAUMA
1. Thigh: Adequately perfused soft tissue usually available for locore-
gional reconstruction.
2. Leg (if possible, provide definitive coverage within 1 week of injury)
a. Gustilo classification (developed for tibial injuries but frequently
applied to other anatomic areas)
i. Grade I: wound <1 cm, minimal soft tissue injury, minimal
comminution
ii. Grade II: wound >1 cm, moderate soft tissue injury, moderate
comminution
iii. Grade III
– Segmental fx with displacement
– Diaphyseal segmental loss
– Associated vascular injury requiring repair
– Farmyard injuries/highly contaminated wounds
– High velocity gunshot wound
– Crushing injury by fast-moving vehicle
• Grade IIIA
○ Wound >10 cm, crushed tissue, contamination, local soft
tissue coverage possible → nail, union minimal delay
• Grade IIIB
○ Wound >10 cm, crushed tissue, contamination, requires
regional or free flap → nail, union delay 25–30 weeks
• Grade IIIC
○ Major associated vascular injury requiring repair for
limb salvage
○ Fracture classified using mangled extremity system
score (MESS)
○ May be necessary to perform below the knee amputation (BKA)
b. Contraindications for salvage of Gustilo IIIC injury in lower extremity
i. Pre-existing severe comorbidity
ii. Tibial loss >8 cm
iii. Ischemia >6 h
iv. Severance of posterior tibial nerve in adults, or sciatic nerve in
anyone (increasingly controversial)
3. MESS: consider amputation if total score >7 (see Table 6.1).
Note: the original article that reported this threshold was retrospective.
Prospective data suggests that up to 1/3 of “nonsalvageable” limbs
may in fact be able to be salvaged with reasonable outcome.

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 142 Lower Extremity

TABLE 6.1 MESS SCORE

Variable Severity Points
Skeletal soft tissue injury Low energy 1 point
Medium energy (open fx) 2 points
High energy (military gunshot 3 points
wound)
Very high energy (gross 4 points
contamination)
Limb ischemia (2× if >6 h isch) Near-normal 1 point
Pulseless, decreased cap refill 2 points
Cool, insensate, paralyzed 3 points
Shock SBP always >90 mm Hg 0 points
Transient hypotension 1 point
Persistent hypotension 2 points
Age (years) <30 0 points
30–50 1 point
>50 2 points

4. Fasciotomy
a. Indication
i. Prophylactically if ischemia >4–6 h
ii. Compartment pressure >30 mm Hg or within 20 mm Hg of dia-
stolic pressure
iii. Clinical dx most suggested by disproportionate level of pain
on passive extension of compartment in conjunction with firm,
swollen extremity; paresthesias, coolness, diminished pulses
and pallor are considered to be inconsistent, late findings
5. Soft tissue reconstruction by region
*Notes: Free flap reconstruction should be preceded with angiogram in
cases of trauma or for a concern of atherosclerosis.
a. Consider end-to-side anastomosis in attempt to preserve distal
perfusion
b. Be aware of the rare but occurring peroneus magnus and other vas-
cular variants that may impact success
6. Thigh: usually adequate soft tissue for reconstruction
7. Knee
a. Gastrocnemius, distally pedicled anterolateral thigh (ALT) flap
8. Proximal 1/3 tibia
a. Gastrocnemius
9. Middle 1/3 tibia
a. Soleus, pedicled perforator fasciocutaneous (e.g., propeller flap)

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 Lower Extremity 143

10. Distal 1/3 tibia

a. Pedicled perforator fasciocutaneous (e.g., propeller flap), free flap,
cross-leg flap, reverse sural artery flap, reversed medial hemisoleus
flap
11. Ankle
a. Skin graft: if paratenon is intact, the Achilles tendon is a suitable
recipient bed; consider use of VAC to prepare the bed
b. Pedicled: lateral calcaneal fasciocutaneous flap, dorsalis pedis
fasciocutaneous flap, retrograde sural artery fasciocutaneous flap,
peroneal retrograde fasciocutaneous flap, extensor digitorum brevis
muscle flap
c. Free: fasciocutaneous or muscle w/ skin graft
12. Foot
a. Wound healing
i. Requires ankle pressure ≥40 mm Hg, toe pressure ≥40 mm Hg,
pulsatile plethysmography, and transcutaneous O2 ≥30 torr.
Note: diabetics may undergo medial calcinosis (medial calcific sclero-
sis of Mönckeberg) of infrageniculate vessels, resulting in falsely
high ABI.
b. Dorsum
i. Skin grafts, local flaps
ii. Pedicled: extensor digitorum brevis muscle flap, retrograde
dorsalis pedis flap, retrograde peroneal artery perforator flap,
retrograde sural artery flap
iii. Free: thin fasciocutaneous as appropriate (e.g., ALT and radial
forearm flaps)
c. Forefoot: local rotation flap, fillet flap, modified medial plantar flap,
cross-leg flap, free flap
d. Midfoot
i. Medial defects on plantar surface: non–weight-bearing → skin
grafts if muscle present
ii. Small defects: heal by secondary intention; V-Y flap, bilobed
flap; rhomboid flap; transposition flap; medially based random
flaps
iii. Medium defects: medially based rotation flaps; pedicled flaps
(abductor digiti minimi flap, abductor halluces brevis muscle
flap, medial plantar fasciocutaneous flap). If over proximal fifth
metatarsal, the flexor digiti minimi muscle may be used
iv. Large defects: fill w/ free muscle flaps and skin graft
v. Charcot joint-related: shave excess bone, consider orthopedic
consultation for mid-/hindfoot fusion to decrease probability of
recurrence
e. Hindfoot: local rotation flap, medial plantar flap, lateral calcaneal
artery flap, cross-leg flap, free flap

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 144 Lower Extremity

B. MANAGEMENT OF BONY INJURY IN LEG

1. Débridement and antibiotic spacers: used as needed until local
infection cleared
2. Bone graft: adequate if segmental defect <6 cm; under vascularized
muscle flaps, up to 10 cm may be acceptable
3. Bone transport: typically reserved for bony defects >6–12 cm
4. Free tissue transfer: recommended if segmental defect >6 cm,
particularly if free flap needed for soft tissue as well

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 7 ■ BURNS

A. INITIAL CARE AND RESUSCITATION

1. The following burns should be referred to a designated burn center
if possible: second- and third-degree burns >10% BSA, full-thickness
burns >5% BSA, any burn to face/hands/eyes/ears/perineum that could
result in cosmetic or functional disability, high-voltage electrical injury
including lightning, inhalation injury, or associated trauma, chemical
burns, burns in patients with major comorbidities (DM, COPD, etc.). In
addition to steps mentioned below, all significant burns merit NGT and
Foley
2. Airway and breathing
a. Always suspect inhalation injury, give 100% oxygen by mask
b. Expose chest to assess breathing
c. Consider early intubation, especially if face/neck burns or inhala-
tion injury
3. Circulation: fluid resuscitation (see section B.2.d., below for calculation
of TBSA) (see Table 7.1)
a. BP may be difficult to assess in extremities; follow pulse, skin
perfusion
b. Two peripheral IVs should be sutured at multiple points to the skin;
as the patient will become edematous, this helps prevent lines from
being dislodged
c. While calculating fluid deficits, start RL at 500 cc/h (adult) or 250 cc/h
(child >5 yo)
i. Parkland formula (for adults w/burn BSA >20%; peds/elderly
BSA >10%); developed by Dr. Charles Baxter
– 4 cc/kg/24 hours: initial guide, follow urine output, other
clinical parameters
– Can also be remembered as
• First 8 hours: LR 2 cc/kg/% TBSA
• Second 8 hours: LR 1 cc/kg/% TBSA
• Third 8 hours: LR 1 cc/kg/% TBSA
• Next 4 hours: 25% albumin 0.1 cc/kg/% TBSA (may give
½ earlier if patient seems to need significantly more than
would be estimated by Parkland formula)
Note: the Brooke formula recommends 2 cc/kg/24 h
• Second 24 hours, consider use of albumin
ii. Galveston formula (designed for children)
5000 cc/m2 burn + 2000 cc/TBSA m2 /24 hours

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 146 Burns

iii. The Parkland, Brooke, and Galveston Formulas ALL use Ringer’s
lactate for the crystalloid, and ALL administer ½ the total fluid
volume over the first 8 hours post-injury (not post-hospital
arrival), with the second ½ total fluid volume distributed over
the ensuing 16 hours. Follow clinical findings to avoid under-
or over-resuscitation. Also, in infants and children less than
30 kg, recommend running a second for maintenance fluid with
D5LR to avoid hypoglycemia
d. Urine
i. UOP: maintain ≥30 cc/h (30–50 ideal) (0.5 cc/kg/h) for adults
or 1.0 cc/kg/h for children
ii. Alkalinization: high voltage burns, crush injuries with myoglo-
binuria/hemoglobinuria at risk of acute tubular necrosis (ATN)
– Not necessary to treat microscopic myoglobinuria, just
grossly obvious cases. Consider use of mannitol and/or
sodium bicarbonate for these patients (i.e., 2 amps sodium
bicarbonate and 25 mg mannitol IV prn)
iii. Other adjuncts
– In the intensive care setting, pediatric patients may benefit
from reducing the hypermetabolic demands on the heart by
treatment with beta-blockade (i.e., propanolol)
– Early use of albumin or excessive fluids required should
prompt placement of PA catheter. Burn patients are almost
always extremely hypermetabolic
4. Nutrition and electrolytes
a. Energy expenditure
i. Nonintubated: 629 – 11 (age) + 25 (wt in kg) – 609 (if obese)
ii. Intubated: 1925 – 10 (age) + 292 (if trauma) + 5 (wt in kg)
+ 281 (if male) + 851 (if >20% TBSA burn)
b. Begin nutritional support postburn day 1
c. Enteral feeds are preferred to parenteral nutrition
d. Only stop tube feeds if residuals are >150% of the hourly rate or
200 cc (whichever is more). Restart, then check again at 1 hour,
2 hours, then q 4 hours
e. Adults with >20% TBSA burns may benefit from anabolic medica-
tions such as oxandrolone
f. Burn patients are essentially psychogenic drinkers; follow their
sodium levels!
*Note: Gatorade, Pedialyte, and ice are restricted fluids regardless of sodium
level.

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 Burns 147

TABLE 7.1 Oral Fluid Management Guidelines for Burn Patients

Serum Na Volume Restricted fl uids
≥136 No restriction Water
133–135 1500 cc Above plus juice, coffee, tea, soda, jello, broth,
watermelon, popsicles (unrestricted: milk, Boost
plus, Deliver, Kindercal, Choice DM, ice cream)
130–132 1000 cc Above restricteds plus milk, ice cream, Kindercal,
Choice DM (unrestricted: Boost Plus, Deliver)
<130 500 cc Same as above

B. THERMAL BURNS
1. Initial patient considerations
a. Avoid hypothermia; wrap in blanket as necessary
b. Remove all jewelry and constricting items; edema will follow major
burns
c. Perform standard trauma assessment: AMPLE hx, PEx w/ neuro
exam, order CBC, chem 7, ABG, CXR, carboxyhemoglobin. Examine
extremity pulses (may need Doppler); if absent, consider escha-
rotomy (can do at bedside w/IV sedation down to but not into sub-
cutaneous tissue). Note that escharotomies do not always follow
the same skin incisions as fasciotomies. Escharotomy on chest
wall may be indicated if impaired ventilation or high pulmonary
pressures
2. Immediate wound considerations
a. Prehospital: copiously irrigate wound with water and protect with
clean dressing/sheet
b. Gently clean, débride loose skin and blisters (blister fluid is proin-
flammatory and a good culture medium). In reliable patients, may
leave intact blisters <1 cm undisturbed
c. Cover with topical antimicrobial (see following, in “Infection”) and
absorbent dressing
d. Accurately estimate burn size and depth (4% TBSA error translates
into 1-liter error in 70-kg patient on the first day)
i. Wallace’s rule of nines (for second- and third-degree burns, in
honor of A.B. Wallace, a Scottish plastic surgeon)
– Adult
• Head: 9%
• Upper extremity: 9%
• Neck: 1%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Lower extremity: 18%

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 148 Burns

– Child
• Head/neck: 18%
• Upper extremity: 9%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Lower extremity: 14%
Note: A patient’s palm (fingers included) is roughly 1% of his/her BSA.
ii. Tetanus prophylaxis: if burn >10% BSA, give 0.5 cc tetanus
toxoid. If tetanus immunization history >10 years ago, or if
received less than 3 total doses, or uncertain, also administer
250 units of tetanus immunoglobulin
– Both Td and TIG are given IM; in short, treat all burn wounds
like dirty wounds
3. Scald injuries
a. Most common form of burn injury in patients <5 yo
b. Unlike other burns that appear white or black (as well as dry and
leathery) with full-thickness burns, third-degree scald burns gener-
ally appear red (as well as dry and leathery)
4. Infection: leading cause of death in adequately resuscitated
patients
a. Mortality used to be from wound sepsis, but now pneumonia is main
risk
b. Generally don’t consider a fever significant in a burn patient unless
≥39.5°C as all patients will be hypermetabolic
c. Topical agents: indicated immediately after débridement (see Table 7.2)

TABLE 7.2 Common Topical Antimicrobial Agents for Burn Patients

Agent Indications/Advantages Caveats
Silver sulfadiazine Painless, non-staining Poor eschar penetration,
(Silvadene) Agent of choice except for Mild reversible
face, ears, thick eschars, neutropenia
or skin grafts (causes
sloughing)
Silvadene + mycostatin Extended coverage against Poor eschar penetration,
(Silvamyco) fungi Mild reversible
neutropenia
Mafenide acetate Good eschar penetration Painful, metabolic alkalosis
(Sulfamylon) Agent of choice for ears, 2° carbonic anhydrase
thick eschars inhibitor
In some patients, allergy
can cause a chondritis
mimicking infection of
auricle
Silver nitrate Broad spectrum Poor eschar penetration,
Electrolyte abnormalities
(continues)

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 Burns 149
TABLE 7.2 (continued )
Agent Indications/Advantages Caveats
Sodium hypochlorite Broad spectrum High doses impair wound
(Dakin’s solution) healing
Neomycin Useful for uncomplicated Minimal
facial burns
Bacitracin Gram (+) coverage Minimal
Agent of choice for face

Polymyxin B Petroleum base moistens Minimal

graft
Polymyxin + mycostatin Extended coverage Minimal
(Polymyco)
Bactroban Good staph Expensive
coverage—slightly better
than bacitracin

C. INHALATION INJURY
1. Generally do not cause direct thermal injury below level of vocal
cords (exception is steam). Therefore, mechanism is from chemical
injury. Majority of house burn fatalities are from anoxia, not thermal
injury
2. Injury may mature up to 48 hours postexposure, and is generally
underappreciated initially
3. Pulse oximetry not accurate. Obtain ABG and carboxyhemoglobin
levels. If have high index of suspicion, treat with non-rebreather mask
oxygen, and sit patient up at 45° to minimize airway edema
a. CO level of 50–60% usually fatal
b. CO level >5% abnormal except in smokers (>10%)
c. Tx until <10% (non-rebreather mask decreases half-life from 240
min to 40 min)
d. Suspect cyanide toxicity if persistent metabolic acidosis despite
what should be adequate resuscitation
i. If have pulmonary artery catheter, may also see increased SvO2
(ddx: sepsis, hepatic failure, AV shunt, nitroprusside toxicity)
ii. Tx: amyl nitrite, sodium nitrite, followed by sodium thiosulfate
4. Bronchoscopy: indicated to document diagnosis, but can also be
therapeutic (suctioning plugs, etc.). Xenon diffusion scan alterative
means of diagnosis
5. Nebulized heparin (decrease cast formation) and acetylcysteine:
(loosen secretions, decrease oxygen toxicity) shown in one study to be
of benefit along with bronchodilators and aggressive pulmonary toilet
(Desai, MH, et al., J Burn Care Rehab, 1998, 19(3):210–2)

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 150 Burns

6. Avoid RSI for intubation (paralyzing patient with edematous airway

high risk for losing airway). Instead, consider incremental use of
morphine and Versed in 5-mg boluses until achieve desired sedation
7. Volumetric diffusive respiration: of some benefit in retrospective
analyses in documented cases inhalation injury
8. Oscillator: most useful in neonates with surfactant deficiency

D. ELECTRICAL BURNS
1. Low voltage (<1000 V)
2. High voltage (>1000 V)
a. Neurologic: neurologic complications can develop early or late after
trauma including encephalopathy, hemiplegia, aphasia, and brain
stem dysfunction up to 9 months after injury
b. Cardiac: arrhythmias, particularly ventricular fibrillation can occur
c. Renal: myoglobinuria can induce acute tubular necrosis. The earli-
est sign of impending problems is a distinctive “cranberry” color
urine; once dark sediment is noted in the urine, more aggressive
treatment (beyond keeping up at 2 cc/kg/h) may be warranted.
Mannitol and sodium bicarbonate may be given in a variety of
methods. Some give a one-time dose of 25 mg mannitol and one
bicarb ampule. Others recommend 25 mg IV of mannitol q6h and a
5% continuous bicarb infusion titrated to urine pH
d. Extremity
i. Tetanic convulsions can lead to fractures/dislocations. Consider
use of c-collar until injury can be ruled out
ii. Fasciotomies (not just escharotomies) must be considered in
any extremities with tense compartments, circumferential
injury, rhabdomyolysis, or other evidence of muscle compro-
mise. Unlike flame burns, damage to deep tissues is much
greater than suggested by skin pathology, especially around
bone that serves as a heat sink for electrical current
e. Abdomen
i. Intraabdominal injury, including bowel perforation, can occur
f. Other
i. Cataracts develop in almost 1/3 of patients after high-voltage
injuries as a long-term complication
3. Lightning
a. May cause temporary (unlike high-voltage electrical injury) paraly-
sis (keraunoparalysis) and/or apnea
b. Evaluate for blast effect (burst tympanic membranes)
c. Can cause arborizing, dendritic burn pattern over skin with (often)
relatively spared internal tissues

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 Burns 151

E. CHEMICAL BURNS
1. General: remove clothing, copiously irrigate with (minimum
15 liters) water. Brush powders away before irrigation
2. Acids: irrigate with water, do not attempt to neutralize, tends to form
eschars
a. Hydrofluoric/oxalic/phosphoric acids: chelate calcium and magne-
sium, causing extensive, extremely painful local tissue destruction
and potential arrhythmias. Copious irrigation with water followed
by immediate application of calcium gluconate gel (2.5%), replac-
ing the gel every 15 minutes until pain is relieved is appropriate. If
significant pain persists after several cycles of gel change, intra-
dermal calcium gluconate (10% at 0.5 cc/cm2 involvement) may
be of use. Alternately, intraarterial calcium gluconate may be tried.
Failure to control the wound could lead to further extension of dam-
age, including demineralization of underlying bone. Admission for
telemetry monitoring (QT interval emphasis) is indicated, and 20
cc of calcium gluconate (10%) should be added to first liter of IV
fluid. Frequent monitoring of calcium, magnesium, and potassium
are indicated
b. Hydrochloric acid: fumes can cause pneumonitis
c. Dichromate salts: consider aggressive débridement (LD 50 is
50 mg/kg)
d. Sulfosalicylic/tannic/trichloroacetic acids: systemic absorption can
lead to hepato/renal toxicity
e. Formic acid: can cause considerable electrolyte abnormalities, met-
abolic acidosis, renal failure, ARDS, and hemolysis. Hemodialysis
may be required for large exposures. Wounds are characteristically
greenish, deeper than are initially apparent, and are optimally man-
aged by excision.
3. Bases (lime, bleach, sodium/potassium hydroxide): liquefactive
necrosis invades more deeply than acid burns
a. Irrigate with water, may take longer than with acids
b. Cement (calcium oxide) leads to similar injury from hydroxyl ion.
Irrigate (water/soap) until effluent has pH <8
4. White phosphorus: used in munitions and fertilizer. Spontaneously
ignites upon contacting air. Immediate management includes covering
with saline-soaked gauze (keep from air). Definite management includes
copper sulfate (0.5%) irrigation and removal of particulate matter/
foreign bodies
5. Hydrocarbons: wounds are typically superficial and heal w/o extensive
surgery, although ignition of the hydrocarbons would cause full-thick-
ness injury. Neosporin or bacitracin are useful to help remove residual
hydrocarbons. Systemic absorption, however, can result in respiratory
embarrassment and/or hepatic toxicity

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 152 Burns

F. SURGICAL MANAGEMENT OF BURN WOUNDS

1. Early excision and grafting
a. All deep partial-thickness and full-thickness burns need to be
excised. Determination of burn depth is clinical (based on color,
texture, sensation) but adjuncts such as laser Doppler imaging
and indocyanine green fluorescence have been occasionally used.
Superficial partial-thickness burns can be treated nonsurgically
b. Removal of burn eschar at the earliest possible time (<24 h) if
physiologically possible gets rid of the nidus of devascularized skin,
which is a source of inflammation and infection. This will decrease
fluid losses, wound sepsis, mortality, and improve long-term func-
tional cosmetic outcome. Uncontrolled inflammation and infection
leads to scarring and contraction
c. Large body surface area burns are treated sequentially. All circum-
ferential full-thickness burns need escharotomy
i. Fasciotomy is rarely indicated. Limit each operation to 10–20%
TBSA excised using tangential excision principles (Weck/Blair
blades). Proceed to excise the back first and then trunk and
extremities
ii. When possible, cover with widely mesh autograft (1:3 or wider)
then cover with allograft if available
iii. Face and palms have traditionally been the last areas grafted
because the dermis is thicker and might heal
iv. Any areas not predicted to heal spontaneously in 3 weeks need
excision and grafting
d. Use of Epicel (cultured epithelial autograft) can be considered if
donor site is limited. Temporary coverage using allograft or tissue-
engineered neodermis (i.e., Integra) might be necessary until the
Epicel becomes available
e. Skin harvesting: manual, electric (Padgett), or air-driven (Zimmer)
dermatomes should be set at 0.008” for elderly or very young.
Otherwise 0.012” is standard thickness. For facial grafts, scalp is
donor site of choice as, but anything above the clavicle is a poten-
tial option. Elsewhere in the body, lateral thigh is used, whereas
lower leg and foot are avoided as these areas heal very slowly.
Clysis using LR with neo-synephrine added (30 mg/L) or tumescent
solution aids in minimizing blood loss
i. Donor site may be managed with:
– Xeroform: staple in place, trim edges once they begin to peel
away from re-epithelializing surface
– Tegaderm is generally preferred to place fine mesh gauze
– Fine mesh gauze: place heat lamp 30–45 cm away until
fully dry; observe for bleeding; outpatients may use blow
dryer for same effect

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 Burns 153

– Biobrane: remove after 24 hours and expose to air, w/o need

for heat lamp; wrap in Ace bandages when ambulating;
open to drain fluid collection, then overwrap with Kling to
re-adhere
– Aquacel (sodium carboxymethylcellulose + ionic silver):
place on wound, maintain for 2 weeks
ii. Recipient site: affix graft with chromic sutures or staples, cover
with single layer of Xeroform, then bolster with VAC or tie-over
cotton bolster soaked in mineral oil
f. Post-op
i. Elevate extremities
ii. Decompress compressive dressings after 30 minutes
iii. Dressing take-downs
– Take down to fine mesh gauze on pod 2 if wound is old (>5
days), dirty, or >30% TBSA. Otherwise, pod 5. Take down to
graft the following day.
– Autografts should be kept covered with neomycin-impreg-
nated fine mesh gauze until closed
– Healed grafts should be kept moist with emollients
– Begin exercising grafted joints on pod 5
– Begin ambulation on: pod 1 if graft above waist, pod 2 if
above the knee, and pod 3 if below the knee
2. Early reconstruction
a. Plastic surgical involvement often centers around the treatment of
facial and extremity burns acutely
b. Facial burns are allowed to declare whether they are full or partial
thickness. Usually determination is possible after 3–5 days
c. Burns determined to be partial thickness and can epithelialize in
3 weeks are allowed to heal spontaneously
d. Otherwise, early excision and grafting is advocated. Coverage using
color match thick (16–18th/1000 th of an inch) autograft is advised
e. Upper back and scalp are potential donors
f. Bilateral facial burns need less attention paid to color matching the
native face
g. Allograft is sometimes used for wound bed preparation before
application of autograft
h. Always involve ophthalmologist in the evaluation of ocular involve-
ment in facial burns. Think corneal burn or exposure keratopathy
i. Corneal exposure should be treated aggressively with lubrica-
tion, moisture goggles or tarsorrhaphy
ii. Lower lids are often necessary, done in stages. Coverage using
split-thickness skin graft for upper lid and full-thickness skin
graft for lower lid has previously been advocated by some
authors

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 154 Burns

i. Coverage of exposed bone and joints in the extremities is some-

times necessary. Exposed dorsal elbow/olecranon, wrist, and hand
are common. Local options are scarce because surrounding skin is
often also burnt. However, use of previously burned or grafted skin
as flaps
i. Should be considered because the underlying fascia is often
spared
3. Late reconstruction
a. Perform late reconstructions and releases of burn scar contrac-
tures after the burn scar has had a period of maturation, usually
6 months
b. Period of rehabilitation and strict follow-up with physical/occu-
pational therapists mandatory. Similar ladder of reconstructive
options including steroid injection, laser treatment (PDL, abla-
tive), scar excision/release followed by skin grafting, local flaps,
tissue expanded flaps, skin substitutes, distant flaps, and free
flaps. Recently, use of composite tissue allotransplantation have
been described for composite facial defects following burn. Most
commonly used techniques include releases using local tissue rear-
rangement (i.e., Z-plasty) or use of full- or thick split-thickness
grafts. Z-plasties have limited utility for broad bands but can be
very helpful in selected situations. Best for linear bands with sur-
rounding laxity
c. Specific examples
i. Neck
– Flexion contractures common. Early release should be con-
sidered to assist with airway manipulation. Minority are
amenable to Z-plasty releases. Scar excision can be con-
sidered so that anterior neck can be uniformly resurfaced.
Most need transverse release from the axis of rotation from
lateral neck to lateral neck followed by coverage with a thick
split-thickness skin graft or full-thickness skin graft
• Recontracture common due to poor graft take over
mobile thyroid cartilage. Flap coverage most durable.
Supraclavicular and deltopectoral transposition flaps
good local options but often not available. Transfer of
free tissue, usu fasciocutaneous flaps (expanded groin
flap, ALT, and expanded pre-fabricated flaps) are good
secondary options
ii. Axilla
– Adduction contractures common. Anterior and/or posterior
axillary folds can be involved; axillary apex usually spared.
Reconstruction difficult as contracture recurs when not
maintained in a stretch position (abduction). Multiple large
Z-plasties a good option when available. Otherwise, mul-
tiple fasciocutaneous flaps from the back based on the
descending branch of the circumflex scapular pedicle as a

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 Burns 155

transposition flap. The thoracodorsal pedicle–based flaps

also possible either as a perforator flap (TAP) or muscle or
musculocutaneous flap
– Release should be focused on circling the axis of rotation
of the glenohumeral joint, sparing the hair-bearing axillary
skin. Complete release is often not possible, especially in
contractures more than a year old because of contracted
pectoralis muscle. Do not release the pectoralis muscle
as the flap skin can be stretched over time with physical
therapy
iii. Elbow
– Flexion contractures common, flap reconstruction preferred
to grafting. Follow the axis of rotation of the radio-humeral
joint. Incomplete release might be secondary to contracted
biceps or development of heterotopic ossification
iv. Hand
– Multiple possible hand deformities, significant morbid-
ity. Most commonly, a continuous band of scar tissue on
the dorsal hand and wrist leads to a hyperextended wrist
and MCPJs with compensatory flexion of the PIPJ (intrinsic
minus position). Release from proximally to distally with
full-thickness skin grafts, immobilize postoperatively with
splints or K-wires. PIPJ prone to irreversibly scarring in
flexed position if not addressed promptly
– First web space contracture: 5-flap Z-plasty for the first web
space excellent choice. Alternately, consider full-thickness
skin graft, reverse radial forearm flap or groin flap
– Other web spaces and burn syndactyly are released with
either Z-plasties or full-thickness skin graft. Functional
release should reproduce the orientation of the normal web
space with 45° slope from metacarpal head toward the
palm. Similar to congenital syndactyly, avoid injury to the
neurovascular bundle and simultaneous release on both
sides of a finger
– Nail bed deformities may result from extrinsic force pulling
the eponychial fold proximally, leading to a retracted nail
fold and hypersensitivity. Dorsal release of DIPJ with cover-
age with a full-thickness skin graft advised
v. Trunk
– Late reconstructive correction infrequently sought. The func-
tionally restricted often involve such large body surfaces
(>70% TBSA) that donor options for skin graft are limited
– Exceptions include young female breast burns as might
constrict breast bud development. Inframammary fold
release can improve breast development although later
asymmetry may warrant breast implant. NAC asymmetry
also common

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 156 Burns

vi. Face
– Large variety of burn facial deformities and surgical strate-
gies. Common complaints: color, texture, cheek tightness
masking facial expressions
– Stigmata frequently needing correction: include lower eyelid
ectropion; short nose with alar retraction or flaring; short,
retruded upper lip; lower lip eversion and inferior displace-
ment; flat facial features and loss of jaw line definition
– Solutions for extrinsic contractures superior to those for
suppleness of skin
– Two broad approaches
• 1: Scar remodeling: proponents assert facial burn scars
improve with time, and process is assisted through laser
(PDL or ablative), Z-plasties, and small skin grafts. They
claim facial subunits replacement with large flaps or
grafts trades one deformity for another
• 2: Scar replacement: proponents argue that remodeling
requires years, and advocate early, aggressive surgery
with flaps. While durable, flaps are bulky and are difficult
to match in color

G. FROSTBITE
1. Occurs with temperature to 28°F (−2°C) resulting in freezing of
tissue, intracellular ice crystal formation, a/o microvascular
thrombosis
2. Immediate tx: includes removing all damp, cold clothing,
immersion in warm (104°F, 40°C) saline (usu 20–30 min), and prn
analgesia. Aggressively tx hypothermia as well
3. A conservative approach to wound débridement is appropriate as
the level of necrosis may not be immediately apparent. Unless wet
gangrene develops, there is no urgency for débridement or ampu-
tation. Early use of angiographic-guided thrombolytics may help
preserve tissue

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 8 ■ SKIN: DERMAL MALIGNANCIES,
VASCULAR ANOMALIES, LASERS,
PEELS, AND INJECTABLES

A. MALIGNANCY
1. Basal cell carcinoma (BCCA)
a. Most common, and usually most indolent, skin cancer; rarely metas-
tasize, 2–5-mm margins usu adequate
i. Waxy, often ulcerated lesion with rolled borders is classic;
originally termed “rodent ulcer”
b. Risk factors: UV exposure, psoralens, arsenic, fair complexion,
immunosuppression, nevus sebaceous of Jadassohn: irregular flesh-
colored nodular/popular lesion usu of head/neck, usu arising in child-
hood, with ~15% risk of malignant transformation to BCCA; 95%
between 40 and 79 years old
c. Types
i. Morpheaform: most aggressive, Mohs surgery
ii. Nodular: most common (70%)
iii. Superficial spreading: usu scaly red lesion on trunk
d. Associated syndromes/conditions
i. Gorlin (basal cell nevus) syndrome: multiple BCCAs, odonto-
genic keratocysts, palmoplantar pitting, etc.
ii. Albinism
iii. Xeroderma pigmentosum
e. Treatment
i. Surgery
– WLE: no standard recommendation for margins, but large/
aggressive variants may warrant up to 1 cm
– Mohs: for recurrent or dz in high value areas (e.g., near
medial canthus), morpheaform
ii. Other (usu reserved for lesions <2 cm or those unfit for surgery)
– 5-FU, imiquimod, XRT, electrodessication and curettage,
laser, cryosurgery

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 158 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables

2. Squamous cell carcinoma

a. Can arise from chronic wound (Marjolin’s ulcer), irradiated skin,
actinic keratoses
b. Risk of LN metastasis 2–5% overall, LN dissection warranted for
palpable LAD; SLNBx investigational
c. Local recurrence and metastasis correlate positively with tumor
thickness >4 mm
i. When arise in area of chronic inflammation, termed “Marjolin’s
ulcer” with up to 20–50% LN metastasis
d. Treatment
i. Surgery
– WLE: no standard recommendations for margins, but many
use 2–10 cm depending on location and size of tumor
ii. Other (usu reserved for lesions <2 cm)
– Curettage, XRT, electrodessication, radiation for poor surgi-
cal candidates
3. Melanoma
a. Fastest growing (epidemiologically) and most lethal skin cancer
b. Types
i. Nodular (15–30%): most aggressive form
ii. Superficial spreading (70%): least aggressive form
iii. Lentigo maligna (10–15%): only form definitely associated with
sun exposure
iv. Acral lentiginous
v. Mucosal
vi. Ocular, amelanotic, desmoplastic
c. Staging
i. Breslow depth is measured from upper granular layer to deep-
est layer of tumor; most important prognostic factor
– T1: ≤1.0 mm thick (ulceration and mitosis ≥1/mm2 → T1b)
– T2: 1.01–2.0 mm thick (ulceration → T2b)
– T3: 2.01–4.0 mm thick (ulceration → T3b)
– T4: >4.0 mm thick (ulceration → T4b)
– N1: One node (a = micrometastasis, b = macrometastasis)
– N2: Two to three nodes (a/b as above, c = intransit met[s]/
satellite met[s] w/o metastatic nodes)
– N3: Four+ nodes, matted notes, or in-transit mets/satel-
lites/metastatic nodes
– M1a: distant skin, subcutaneous, or nodal metastasis
– M1b: lung metastasis
– M1c: all other visceral metastasis, any distant metastasis,
elevated LDH
– Stage 0: melanoma in situ; 99.9% 5-year survival
– Stage I: T1a–T2a, 85–99% 5-year survival
– Stage II: T2b–T4b, but N0, 40–85% 5-year survival

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 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables 159

– Stage III: regional LN metastasis, 25–60% 5-year survival

– Stage IV: any M(+), 9–15% 5-year survival
d. Treatment
i. WLE
– In situ: 0.5 cm margins
– Stage Ia: 1 cm margins, SLNBx for any stage I over 1 mm
thickness or ulcerated lesion
– Stages Ib, IIa, IIb: SLNBx, 2 cm margins, IFN alfa-2a for IIb
– Stages IIc, III: 2–4 cm margins; IFN alfa-2a for IIc, III; thera-
peutic lymph node dissection for macrometastases
ii. No treatment has been shown to increase survival in stage IV
disease. Therapies under investigation include surgery, che-
motx, immunotx, XRT
4. Giant melanocytic nevus
a. Bittencourt et al., J Clin Pathol. 2007 Jan;60(1):82–4: 20 cm is larg-
est diameter in adults, or projected to be that large by adulthood
b. Piney: so large that cannot be completely excised and closed by pri-
marily by adjacent tissue advancement in one operation
c. Developmental error of embryonic neural crest cells
d. Risk of degeneration
i. Deeper, more nodular, increased risk
ii. Peak incidence of embryonic cell type melanoma during first
year
iii. About ½ of malignancies in these lesions in first 3 years of life,
60% by childhood (10 yrs old), 70% by puberty
iv. Incidence of melanoma increases again in third decade
v. While lifetime risk reported 1–40%, most estimates range for
lesions >3 cm as ~6%, <3 cm, 1–5%
vi. If lesion homogeneous and bx = intradermal, may observe. If
junctional, deep dermal, or cellular blue nevus, recommend
excision
e. Management
i. Excision and:
– Serial excision
– Tissue expansion, serial excision

B. VASCULAR ANOMALIES
1. Infantile hemangiomas
a. Epidemiology/etiology
i. Most common tumors of infancy (up to 12% by 1 year of age in
white children)
ii. Possibly result from embolized placental cells or clonal expan-
sion of endothelial cell via germline mutation

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 160 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables

*Note: Distinguish from the rarer congenital hemangioma, which is fully devel-
oped at birth and may be classified as either rapidly involuting congenital
hemangioma (RICH) or non-involuting congenital hemangioma (NICH).
Mulliken JB et al., “Vascular anomalies: classification, diagnosis, and
natural history,” Facial Plast Surg Clin North Am. 2001 Nov;9(4):495–504
iii. Tx is observation, not steroids
b. Pathology/presentation
i. Typically appear in first 2 weeks after birth, although deep or
visceral ones may take several months
ii. 80% solitary, most common on head, neck (60%), followed by
trunk (25%) and extremities (15%)
iii. >5 cutaneous hemangiomas → increased risk of visceral hem-
angioma; obtain abdominal CT scan
iv. Most spontaneously resolve (50% by 5 y, 70% by 7 y, 90% by 9 y,
little change after 10 y however). More rapid involution (improved
by fourth year) results in more favorable long-term appearance
v. Once resolved, do not recur
vi. Phases
– Proliferating: typically no longer than 20 months
– Involuting: 6 mo–5 yo
– Involuted: usu after 5 yo
vii. Complications that may prompt intervention
– Bleeding, ulceration (10%)
– Airway compromise (subglottic hemangiomas)
– Visual obstruction (periorbital: note amblyopia and other
visual changes—strabismus, optic atrophy can develop in
only 1 week in infants)
– Kasabach-Merritt syndrome (thrombocytopenia from local
intravascular coagulopathy)
• Only seen with kaposiform hemangioendotheliomas and
tufted angiomas
– Congestive heart failure (CHF)
• Only seen with diffuse neonatal hemangiomatosis or
large visceral (esp hepatic) hemangiomas
c. Dx
i. Physical exam: Most often in head/neck region. Usually not
present at birth, but invariably by 6 months of age. Color (red,
blue, purple) varies with depth.
ii. Radiographic
– U/S: homogenous, high degree of shunting
– CT: well-circumscribed, homogeneous masses
– MRI: T1 intermediate intensity; Tw moderate hyperintensity,
enhances w/gadolinium
d. Tx
i. Majority require none. Up to 65% involute by 5 yo, and 70% by 7 yo,
and 90% by 9 yo, and tx is reserved for complications such as bleeding,
infections, visual impairment, ulceration, skeletal distortion, nasopha-
ryngeal or external ear obstruction, Kasabach-Merritt, and CHF

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 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables 161

ii. Nonsurgical
– Steroids (side effects include growth retardation if prolonged
use)
• PO (usual): prednisone 2–3 mg/kg × 2–3 weeks, then taper
• Intralesional: triamcinolone (40–80 mg) or betametha-
sone (6–12 mg) under general anesthesia
○ Complications include skin necrosis and blindness
from embolization (most avoid injecting eyelid lesions)
• IV (reserved for Kasabach-Merritt)
– IFN-alpha (side effects include flu-like syndrome, neutrope-
nia, abnormal LFTs, and spastic diplegia)
• Reserved for failure of steroids, particularly in life- or
vision-threatening cases
• SC injection 1–2 M u/m2 /day; tx may last several years,
with some degree of regression in >80%, but complete
resolution in <50%
– Laser (limited by depth)
• Pulseddye lasers most common, but CO2, Nd-YAG, others
used with some effect
iii. Surgery: usu reserved for managing urgent situations
refractory to medical tx (e.g., eyelid lesion causing amblyopia)
or excision of residual appendages after involution

C. VASCULAR MALFORMATIONS
1. Classifi cation
a. Slow-flow
i. Capillary
– Formerly called port wine stains
• When in trigeminal distribution, may be part of Sturge-
Weber syndrome
○ Associated with glaucoma, seizures, leptomeningeal/
choroid plexus calcification
○ Warrants referral to neurologist, brain MRI; if in V1,
ophthalmology
– Skin lesion usu managed with pulsed dye laser (585 nm)
ii. Lymphatic
– Classification
• Macrocystic (formerly cystic hygroma)
• Microcystic (formerly lymphangioma)
– Associated with soft-tissue and/or bony hypertrophy
– Size often increases with inflammation/infection, or hemor-
rhage into lesion
– Tx
• Aggressively address infections or sources of inflamma-
tion to minimize sx

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 162 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables

• Aspiration and sclerosis (sodium tetradecyl sulfate, doxy-

cycline, OK-432, etc.)
• Surgical resection is challenging and rarely is complete
excision possible
– Venous
• Clinically, usually swells with dependence, often associated
with pain and stiffness and thrombosis
• Coagulopathy (localized, or even DIC) may follow traumatic
insult to lesion
• T2-weighted MRI best for dx
– Tx
• Support stockings and aspirin (prevent phlebothrombo-
sis) for LE lesions
• Sclerosing with 1–3% sodium tetradecyl sulfate often
initial tx
• Surgery for large, symptomatic, or disfiguring lesions, or
to excise residual malformation may be considered
b. Fast-flow
i. Arteriovenous (AVM)
– Clinically, may be associated with thrill/bruit, skin changes,
increased cardiac output (large lesions)
– Tx: warranted for limb-threatening ischemia, local ischemic
pain, bleeding, or cardiac demand issues
• Proximal embolization or ligation contraindicated (recruits
additional feeding vessels)
• Superselective embolization followed 1–3 days later by
resection is best ablative approach
– Associated syndromes
• Osler-Weber-Rendu disease (hereditary hemorrhagic telan-
giectasias, HHT): telangiectasias, multiple mucosal, vis-
ceral, cutaneous AVMs; autosomal dominant transmission
• von Hippel-Lindau syndrome: hemangiomas of the retina,
cerebellum, possibly other organs and cysts of pancreas,
liver, adrenals, a/o kidneys; may also have seizures a/o
mental retardation
c. Combined
i. Mafucci syndrome: multiple cutaneous hemangiomas (or
venous anomalies) with enchondromatoses (80% hand: fin-
gers, toes, proximal extremities) with multiple cutaneous hem-
angiomas. Involved bones usually shortened and deformed. Up
to 25% develop chondrosarcomas. Malignant degeneration of
hemangioma also reported
ii. Klippel-Trenaunay-Weber syndrome: cutaneous capillary mal-
formation of extremity and venous or lymphatic malformation
(no AVMs/AVFs). Extremity hypertrophy (95% lower extremity).
Surgery rarely helpful
iii. Parkes Weber syndrome: cutaneous capillary AVMs/AVFs; skel-
etal/soft-tissue hypertrophy, especially in lower extremities

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 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables 163

D. LASERS AND CHEMICAL PEELS

1. Lasers and chemical peels
Note: Although lasers may be targeted against a variety of chromophores, in clini-
cal cosmetic practice they (along with peels) are used to resurface the face,
diminishing fine wrinkles.
a. Fitzpatrick skin classification (Fitzpatrick TB, Arch Dermatol,
1988;124:869)
i. Type I: white – never tans (always burns)
ii. Type II: white – tans only with difficulty (usually burns)
iii. Type III: white – average tan (sometimes burns)
iv. Type IV: moderate brown – easily tans (rarely burns)
v. Type V: dark brown – tans very easily (very rarely burns)
vi. Type VI: black – tans very easily (almost never burns)
b. Precautions
i. Higher Fitzpatrick skin classification translates into increased
risk of hyperpigmentation after treatment
– Pretreatment with bleaching agents such as 4% hydroqui-
none and 0.05% tretinoin decreases this risk
ii. Oral antiviral prophylaxis (e.g., acyclovir) is indicated for any-
one with history of varicella or HSV
iii. Management of hyperpigmentation
– 4% hydroquinone (use test patch first, as irreversible exog-
enous ochronosis is a rare side effect)
(See Table 8.1)
TABLE 8.1 Commonly Used Lasers in Plastic Surgery

Laser Type Wavelength (nm) Indications/Target Chromophore

Argon 488, 514 Vascular lesions

Argon dye 585 Vascular lesions

Copper vapor 512, 578 Vascular and pigmented lesions

KTP 532 Vascular lesions

Pulsed dye 585 Vascular lesions

Pulsed dye 510 Red tattoo ink, pigmented lesions

Q-switched ruby 694 Tattoos, pigmented lesions

Q-switched alexandrite 755 Tattoos, pigmented lesions

Q-switched YAG 1064, 532 Tattoo (black 1064, red 532)

CO2 10, 600 Skin resurfacing, cutting, ablation

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 164 Skin: Dermal Malignancies, Vascular Anomalies, Lasers, Peels, and Injectables

2. Chemical peels (in increasing order of depth of penetration)

*Note: Use same antiviral prophylaxis when resurfacing as for lasers.
a. Jessner’s solution (resorcinol, salicylic acid, lactic acid, ethanol)
b. TCA 20–50% (pretreatment with Retin-A improves uniformity of
peel)
c. Phenol (requires cardiac monitoring if entire face is treated due to
risk of arrhythmias)
d. Baker-Gordon formula includes: water, phenol, liquid soap, and cro-
ton oil
e. Glycolic acid

E. INJECTABLE FILLERS AND BOTOX

1. Fillers
a. Add volume for cosmetic purposes; almost all are of limited duration
b. Common agents
i. Restylane: cross-linked hyaluronic acid from Streptococci.
Frequently used for lip or nasolabial fold, injected at interface
between dermis and subcutaneous tissue. Effects significantly
diminish after 1 year
ii. Hydroxyapatite (Radiesse): lasts longer, requires less volume
for same effect than Restylane. However, more expensive, not
as useful for fine wrinkles or lips
iii. Sculptra: polylactic acid indicated for variety of conditions, includ-
ing HIV lipodystrophy. Effects noticeable up to 2 years, reportedly
due to fibroblast production and collagen synthesis
2. Botox
a. Botulinum toxin A prevents acetylcholine release into synapse, pre-
venting associated muscle firing
b. Wide variety of clinical applications: common cosmetic indications
include rhytids of forehead, glabella, perioral region, crow’s feet,
brow ptosis (up to ~6 mm) and platysmal bands
c. Aesthetic effects typically last 3–6 months

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 INDEX
Note: Italicized page locators indicate figures; tables are noted with t.

A Allopurinol
Abbé flap, lips, 41 for Dupuytren’s disease, 109
Abdominal wall reconstruction, flap survival and, 15
137–138 for gout, 111
Abdominoplasty, aesthetics, 139 ALND. See Axillary lymph node
Abducens nerve (CNVI), 24t dissection
Abductor digit minimi, 88t Alveolar bone grafting, 70
Abductor pollicis brevis, 89t Alveolar cleft, 66
Abductor pollicis longus, 89t Alveolar process, 22
Accommodation, pupils, 30 Alveolar ridge, 32
Acetylcysteine, inhalation Ameloblastoma, 60
injury, 149 Amides, 19
Achondroplasia, 128 Amputation, leg trauma, 141
Acids, chemical burns, 151 Amrinone, flap survival and, 15
Actinic cell carcinoma, parotid Anastomoses
gland, 58 end-to-end, 13
Advancement flap, 5 end-to-side, 13
AER. See Apical ectodermal ridge Anatomic snuff box, 84
Aesthetics, 79–82 Anesthesia
abdominoplasty, 139 local, 19
blepharoplasty, 81–82 regional, 17–19
brow lift, 82 Angle fracture, mandibular,
evaluate, 79 treatment, 53–54
injectable fillers and Botox, 164 Angulation fracture, 98
liposuction, 139 Ankle, reconstruction, 143
massive weight loss Anterior interosseous
patients, 139 syndrome, 116
rhinoplasty, 79–80 Anterolateral thigh (ALT) flap, 38
rhytidectomy, 80 Antia-Buch technique, ear, 43
Afferent papillary defect, 30 Anticoagulants, flap survival
Airway and breathing, and, 15
burns, 145 Antimicrobial agents, topical, for
Alar batten graft, nose, 39 burn patients, 148t–149t
Albinism, 157 Apert syndrome, 73, 127
Aleve, inflammation and, 2 Apical ectodermal ridge, 121
Alloplastic implants, orbital Areolar reconstruction, 132
fractures, 48 Areolar tattoo, 132
Alloplastic reconstruction, Argon dye laser, 163t
TMJ, 41 Argon laser, 163t
Alloplasts, mandible, 40 Arnold’s nerve, 31

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 166 Index
Arthritides, 110–111 Benign soft tissue tumors, hand
Arthrogryposis, 123 and peripheral nerve
Aspirin diagnosis, 112
coagulation and, 1 ganglia, 111
flap survival and, 15 treatment, operative and
for vascular malformations, 162 nonoperative, 112
Auditory nerve (CNVIII), 24t Biceps, 87t
Augmentation, breast, 134–135 Biceps femoris flap, skin paddle,
Auriculotemporal nerve, 31 POC, arc of rotation, size,
Autologous breast reconstruction vessel, nerve, 11t
advantages, 129–130 Bicoronal classification,
chemotherapy, 130 craniosynostosis, 72
disadvantages, 130 Bicuspids, 32
free flap, 131 Bier block, 19
free flap challenges, 131 Bilobed flap, nose, 38
irradiation (XRT), 130 Binder syndrome, 74
options, 130–131 Bite wounds, 108
Axial flaps, facial wounds, 37 Blepharochalasis, 81
Axilla, burn wound management, Blepharoplasty, 81
154–155 Blow-in fractures, orbital, 48
Axillary block, 18 Bone cysts, hand and peripheral
Axillary lymph node nerve, 113
dissection, breast Bone grafts, 4
reconstruction, 130 bony injury in leg, 144
Axillary nerve, 86 orbital fractures, 48
Axonotmesis, Sunderland, Bones, eye, 28
lesion, usual course, Bone transport, bony injury in leg, 144
management, 114t Bony tumors, hand and
peripheral nerve
B benign, 112–113
Bacitracin, for burn patients, 149t malignant, 113
Bactroban, for burn Botox, clinical applications and
patients, 149t aesthetic effects, 164
Baker-Gordon formula, chemical Boutonnière deformity, 93
peel, 164 Bouvier maneuver, 117
Baker’s classification, capsular Brachial artery, vascular supply, 84
contracture, breast Brachialis muscle, 87t
augmentation, 135 Brachial plexus
Banner flap, nose, 38 components, 85
Basal cell carcinoma, risk factors, injury, features, 114–115
types, associated peripheral nerves, 85–86
syndromes/conditions, regional anesthesia, 18
treatment, 157 Brachydactyly, classification,
Bases, chemical burns, 151 treatment, 126
Baxter, Charles, 145 Breast augmentation
BCCA. See Basal cell carcinoma choice of approach, 134
Benelli approach, mastopexy, 134 choice of implant, 134

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 Index 167
choice of placement, 135 Burn wounds
risks, 135 early reconstruction, 153–154
Breastfeeding, reduction late reconstruction, 154–156
mammoplasty and, 132 Burow’s triangles, advancement
Breast ptosis, 133 flap, 5
Breast reconstruction Buttresses, NOE fractures, 49
augmentation, 134–135
autologous vs. prosthesis-based, C
129–131 Calcium channel blockers
considerations, 129 for Dupuytren’s disease, 109
goals, 129 flap survival and, 15
immediate vs. delayed, 129 Camptodactyly, 124
nipple and areolar Canines, 32
reconstruction, 132 Capsular contracture, breast
reduction mammoplasty, augmentation
132–134 Baker’s classification, 135
Breasts hematoma, 135
anatomy, perfusion, and infection, 135
innervation, 129 prevention and treatment, 135
tuberous, 134 Carpal coalition, 123
Breslow depth, melanoma, 158 Carpal fractures, scaphoid,
Brewerton views, 97 104–106
Bronchoscopy, inhalation Carpal instabilities and fracture
injury, 149 dislocations, scapholunate
Brooke formula, burns and, instability, 106–107
145, 146 Carpal tunnel syndrome
Brow, position and approaches, 82 clinical symptoms, 115
Brunelli-type reconstruction, 107 nerve conduction studies
Buccal, regional anesthesia, 18 and, 114
Buccal space, 22 Carpal tunnel view,
Buccinator muscle, 26t radiography, 97
Bunnell-Stiles transfer, 118 Carpenter’s syndrome, 74
Bupivacaine, maximum dose, 19 Carpometacarpal joint, 83
Burns, 145–156 Carpus, osteology, 83
antimicrobial agents for, Cartilaginous disk, 22
148t–149t Cataracts, electrical burns and, 150
chemical, 151 Cat bite wounds, 108
electrical, 150 Celebrex, inflammation and, 2
frostbite, 156 Celecoxib, inflammation and, 2
inhalation injury, 149–150 Cellulitis
initial care and resuscitation, capsular contracture, breast
145–147 augmentation, 135
oral fluid management hand and peripheral nerve, 107
guidelines, 147t Central incisors, 32
surgical management of Champy’s principles, for ORIF
wounds, 152–156 miniplates, 53
thermal, 147–149 Checkrein ligaments, 90

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 168 Index
Chemical burns, general, acids, Comminuted fracture, 98
bases, white phosphorus, Compartment syndrome, 116
hydrocarbons, 151 Compression neuropathies, hand
Chemical peels, 163, 164 compartment syndrome, 116
Chemosis, 30 median nerve, 115–116
Chemotherapy, breast radial nerve, 116
reconstruction, 130 ulnar nerve, 116
Chest wall reconstruction Condylar fracture, treatment, 53
indications, 137 Condylar process, mandible, 22
options, 137 Congenital, hand and
sternotomy infections, 137 peripheral nerve
Chondrosarcoma, hand, 113 classification (Swanson),
Cilostazol, coagulation and, 1 121–128
Circulation, burns, 145 congenital constriction band
Cleft hand, 122 syndrome, 127
Cleft lip (CL) duplication
associations, 65 mirror hand, 125
classification, 65–66 polydactyly, 125–126
epidemiology, 64 embryology, 121
etiology, 64–65 failure of differentiation/
management, 67 separation of parts
race, type, location, gender, 64 arthrogryposis, 123
surgery, 67–68 camptodactyly, 124
Cleft palate (CP) carpal coalition, 123
anatomy, hard and soft clinodactyly, 124
palates, 66 Poland’s syndrome, 123
diagnosis, 69 syndactyly, 123–124
embryology, 65 vascular anomalies, 124
etiology, 69 failure of formation
management, 69–70 longitudinal arrest, 121–123
muscles, 66–67 transverse arrest, 121
surgery, 68 generalized syndromes, 127–128
Cleland’s ligament, 90 overgrowth
Clinodactyly, 124 hemihypertrophy, 126
Clopidogrel, coagulation and, 1 macrodactyly, 126
Closed boutonnière, 93 undergrowth, brachydactyly,
Coagulation, 1 126–127
Colchicines Congenital, head and neck
for Dupuytren’s disease, 109 craniofacial clefts, 61–70
for gout, 111 craniosynostosis, 70–76
inflammation and, 2 embryology of face, 61
Collagen, 2 etiology of craniofacial
Collagenase, for Dupuytren’s anomalies, 61
disease, 109 facial masses, 77
Combined median and ulnar nerve microtia, 76–77
palsy, goals, treatment orthognathic surgery, 78–79
options, 118 prominent ears, 77

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 Index 169
Congenital constriction band D
syndrome Dakin’s solution, for burn
etiology/epidemiology, 127 patients, 149t
Patterson classification, 127 Deep space infections, 108
Conjunctiva, palpebral and bulbar Deferoxamine, flap survival and, 15
components, 29 Dell classification,
Consensual papillary macrodactyly, 126
response, 30 Deltopectoral flap, 37
Contraction, 2 arc of rotation, POC, max. size,
Converse tunnel procedure, source vessels, sensory
ear, 43 nerves, 9t
Copper vapor laser, 163t Dental terminology, 32
Corneal burns, 153 Dentoalveolar fracture, 51
Coronal classification, De Quervain’s tenosynovitis, 111
craniosynostosis, 71–72 Dermal malignancies
Coronal surgical approach, 34 basal cell carcinoma, 157
Coronoid process, mandible, 22 giant melanocytic nevus, 159
Corrugator muscle, 26t melanoma, 158–159
CO2 laser, 163t squamous cell carcinoma, 158
Cranial clefts (no. 10-14), 63–64 Dermatochalasis, 81
Cranialization, 45 Dermis, 3
Cranial nerves, 24t–25t Dermoid cyst, 77
Craniofacial anomalies, Dextran, 15
etiology of, 61 Diabetics, foot trauma, 143
Craniofacial clefts, 61–63 Dieffenbach flap, ear, 43
Craniosynostosis, 70–76 Digastric muscles, 26t
cause, 70 Digital block, 18–19
commonly asked about Digital nerves, 87
syndromes and Dingman maneuver, zygoma
sequences, 74–77 fractures, 46
diagnosis, 71 Direct cutaneous pedicle, 8t
incidence, 70 Direct papillary response, 30
pathophysiology, 70–71 Dislocations
single suture, classification, 71 fixation, 104
bicoronal, 72 open, 104
coronal, 71–72 perilunate, 103
lambdoid, 72–73 Distal palmar crease, 84
metopic, 72 Distal phalanx fractures
sagittal, 71 base of distal phalanx,
syndromic, 73–74 Types I-III, 102
Crouzon syndrome, 73 proximal metaphysis, 102
Cubital tunnel syndrome, 116 shaft, 102
Cupid’s bow, lips, 32 Tuft, 101
Cutler-Beard flap, eyelid, 42 Distal radioulnar joint, 83
C-V flap, nipple and areolar Distal wrist flexion crease, 84
reconstruction, 132 Distraction osteogenesis, 41
Cytokines, 3 Dog bite wounds, 108

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 170 Index
Dorsal interossei, 88t Electrolytes, burn patients and, 146
Dorsalis pedis flap, arc of rotation, Elson test, 93
POC, max. size, source Encephalocele, 77
vessels, sensory Enchondromas, hand bones, 112
nerves, 10t Enteral feeds, burn patients
Dorsal nasal flap, nose, 38 and, 146
Dorsal nerve block, 18 Epidermis, 3
Dressing, burn wounds, 153 Epiphora, 30
DRUJ. See Distal radioulnar joint Epitendinous suture, 92
Dry eyes, etiology and evaluation, 30 Eponychium, 94
Duchenne sign, 117 ERND. See Extended radical
Dufourmentel variant, rhomboid neck dissection
flap, 7 Erythroplakia, 55
Dupuytren’s disease Esmarch, hand and peripheral
arthritides, 110–111 nerve, 128
avascular necrosis, 110 Esophagus, reconstruction, 40
epidemiology and etiology, 109 Esters, 19
pathoanatomy and Ethmoidal sinuses, 21
pathophysiology, 109 Ethmoid bone, 28
treatment, 109–110 Ewing’s sarcoma, hand, 113
Dyschondroplasia, 128 Excision, burn wounds, 152–153
Dystrophic dwarfism, 128 Expanders, skin, 17
Extended radical neck
E dissection, 57
Ear reconstruction, 43–44 Extensor carpi radialis brevis, 87t
helical and upper-third Extensor carpi radialis longus, 87t
defects, 43 Extensor carpi ulnaris, 87t
lower-third defects, 43 Extensor compartments, from radial
middle-third defects, 43 to ulnar, 94
total ear defects, 43–44 Extensor digiti minimi, 88t
Ears Extensor digitorum communis, 88t
external structure, vasculature, Extensor hallucis longus flap,
innervation, 31 skin paddle, POC, arc
lacerations, 36 of rotation, size, vessel,
prominent, pathoanatomy and nerve, 12t
surgery, 77 Extensor indicis, 88t
Ehler-Danlos syndrome, 2 Extensor pollicis brevis, 89t
Elastin, 3 Extensor pollicis longus, 89t
Elbow Extensor tendons, anatomy, 92–94
burn wound management, 155 Eyebrow, lacerations, 36
muscle, origin/insertion, nerve, Eyelid
root, 87t anatomy, 29
physical evaluation, 95t lacerations, 36
Electrical burns reconstruction, 42–43
high voltage, 150 full-thickness defects, 42–43
lightning, 150 goals, 42
low voltage, 150 partial thickness defects, 42

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 Index 171
Eyes Fingers
anatomy, 28–29 DIP
dry, etiology and evaluation, 30 muscle, origin/insertion,
opening, upper and lower nerve, root, 88t
lids, 30 physical evaluation, 96t
physiology, 30 MCP
muscle, origin/insertion,
F nerve, root, 88t
Face physical evaluation, 95t
embryology of, 61 PIP
zygoma, 21 muscle, origin/insertion,
Facial burns nerve, root, 88t
early reconstruction, 153 physical evaluation, 95t
scar remodeling, 156 regional anesthesia, 18
scar replacement, 156 Fingertip
Facial clefts, reconstruction deficits, 119
of, 64 heterodigital flaps, 120
Facial expression, muscles of, homodigital advancement
26t–27t flaps, 119
Facial fissures and foramina, 22 skin graft, 120
Facial fractures, 44–46 Fissures, head and neck, 22
complications, 46 Fitzpatrick skin classification,
general, 44 lasers and chemical
physical exam, 44 peels, 163
presentation, 45 Flag flap, 120
radiography, 44 Flap physiology
treatment, 45–46 flap delay, 14
Facial masses, 77 hemodynamics of flap
Facial nerve palsy, 60 transfer, 14
Facial wounds, reconstruction, 35 ischemia-induced reperfusion
axial flaps, 37 injury, 14
free tissue transfer, 38 regulation of skin perfusion, 13
general reconstructive Flaps
considerations, 37 advancement, 5
lacerations, 35–37 ankle, 143
local flaps, 37 arterial insufficiency and,
musculocutaneous flaps, 38 15–16
Fanconi anemia, 127 autologous breast
Fasciotomy, indication, 142 reconstruction, 130
Fat, grafts, 4 chest wall reconstruction, 137–138
Felon, 107 classification, 8t, 10t
Fibrinogen, for platelet ear, 43
aggregation, 1 examples, 11t–12t
Fillers, injectable, 164 eyelid, 42
Fingernails facial wounds, 37–38
anatomy and physiology, 94 foot trauma, 143
injury, 94 lips, 42

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 172 Index
Flaps (Continued) Foramina, head and neck, 22
managing perfusion problems, Forearm
arterial and venous, 16 muscle, origin/insertion, nerve,
nipple and areolar root, 87t
reconstruction, 132 physical evaluation, 95t
nose, 38 Forehead flap, 37
perfusion issues, 15–16 Fractures
prefabricated, 13 facial, 44–46
prelaminated, 13 hand and peripheral nerve
reversed, 13 epidemiology, 96
rhomboid, 6, 7 evaluation, 96
rotation, 5 patterns and nomenclature, 96
skin expansion and, 17 reduction, fixation, and
soft tissue reconstruction, immobilization, 96–107
hand, 119–121 mandibular, 52–54
soft tissue reconstruction, lower maxillary, 50–51
extremity, 142 nasal, 49
types, by tissue involved, 8, 13 NOE, 49–50
vascular supply, 4 orbital, 47–49
venous insufficiency and, 15 panfacial, 51–52
V-Y advancement, 5 zygoma, 46–47
Flap survival, optimizing, physical Free flaps, 120
and pharmacologic abdominal tissue, 131
factors, 15 buttock tissue, 131
Flap vasculature, complex midfacial defects, 41
macrocirculation, 7–8 thigh tissue, 131
Flap viability, monitoring, physical Free tissue transfer
exam, dye, other, 16 bony injury in leg, 144
Flexor carpi radialis, 87t head and neck reconstruction, 38
Flexor carpi ulnaris, 87t Frey’s syndrome, 59
Flexor digitorum profundus, 88t Froment’s sign, 118
Flexor digitorum Frontal bone, 28
superficialis, 88t Frontalis muscle, 26t
Flexor pollicis brevis, 89t Frontal sinuses, 21
Flexor pollicis longus, 89t Frostbite, 156
Flexor tendons Full-thickness reconstruction,
anatomy, zones I-V, 90 lips, 41
surgical options, 91 Furlow (double-opposing)
techniques, 91–92 platoplasty, 69
Fongue flap, 37
Foot G
dorsum, 143 Galveston formula, burns and, 146
forefoot, 143 Gamma-interferon, for Dupuytren’s
hindfoot, 143 disease, 109
midfoot, 143 Gastrocnemius, soft tissue
wound healing, 143 reconstruction, 142

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 Index 173
Gastrocnemius flap, skin paddle, H
POC, arc of rotation, size, Hamate, 83
vessel, nerve, 11t Hand and peripheral nerve
Genioglossus muscle, 26t congenital, 121–128
Geniohyoid muscle, 26t evaluation, 94, 95t–96t
Giant-cell tumor of bone, fractures and
uncommon in hand, 113 dislocations, 98–107
Giant-cell tumor of tendon sheath, infection, 107–108
hand, 112 inflammatory and degenerative
Giant melanocytic nevus, 159 disorders, 109–111
Gillies’ maneuver, zygoma injection, 108
fractures, 46 ligaments, 89–90
Gilula’s lines, 97 muscles, 87t–89t
Girdlestone procedure, pressure nerves, 85–87
ulcers, 138 osteology, 83–84
Glomus tumor, hand, 112 radiography, 96–98
Glossopharyngeal nerve (CNIX), 25t soft tissue reconstruction,
Gluteus maximus flap, skin paddle, 119–121
POC, arc of rotation, size, surface landmarks, 84
vessel, nerve, 12t tendons, 90–94
Glycolic acid, chemical peel, 164 tourniquet and Esmarch, 128
Glycosaminoglycans, 3 tumors, 111–119
Goblet cells, lacrimal system, 30 vascular supply, 84–85
Goldenhar syndrome, 74 Hand/digits
Gorlin syndrome, 157 burn wound management, 155
Gout, diagnosis and treatment, 111 large defects of, 120–121
Gracilis flap, skin paddle, POC, arc small defects of, 120
of rotation, size, vessel, Head and neck
nerve, 11t aesthetics, 79–82
Grafts, 4 anatomy, 21–23
burn wounds, 152–153 congenital, 61–79
mandible, 40 cranial nerves:
nose, 39 innervation, 24t–25t
Grayson’s ligament, 90 ear, 31
Great auricular nerve, 31 eye, 28–30
Greater auricular peripheral lips, 32–33
nerve, 25t lymphatics and salivary
Greater palatine, regional glands, 28
anesthesia, 17 musculature, 26t–27t
Greenstick fractures, 98 nose, 31
Groin flap, 120 oral cavity and teeth, 32
arc of rotation, POC, max. size, osteology, 21–22
source vessels, sensory peripheral nerves:
nerves, 8t, 10t innervation, 25t
Gustilo classification, leg regional anesthesia, 17
trauma, 141 scalp, 32

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 174 Index
Head and neck (Continued) IL-6, 3
soft tissue reconstruction, IL-8, 3
35–44 Immobilization. See Reduction,
spaces, 22–23 fixation, and immobilization
surgical approaches, 33–35 Implant, breast augmentation, 134
trauma, 44–54 Incisors, 32
tumors, 55–61 Infantile hemangiomas, 159–161
vasculature, 23 diagnosis, 160
Hearing defects, microtia and, 76 epidemiology/etiology, 159–160
Hemifacial microsomia, 40, 74 pathology/presentation, 160
Hemihypertrophy, 126 treatment, 160–161
Hemophilia A, 1 Infection, hand and peripheral nerve
Hemophilia B, 1 bite wounds, 108
Heparin cellulitis, 107
flap survival and, 15 chronic, 108
nebulized, inhalation injury, 149 deep space infection, 108
Herceptin, 130 felon, 107
Heterodigital flaps, 120 paronychia, 107
High median nerve palsy, 117 septic joint, 108
High ulnar nerve palsy, 118 tendon sheath infection
Holt-Oram syndrome, 127 (tenosynovitis), 107–108
Homodigital flaps, 120 Inferior alveolar, regional
Horizontal buttress, NOE anesthesia, 17
fractures, 49 Inferior alveolar peripheral nerve, 25t
Horner’s syndrome, 30 Inferior gluteal artery perforator
Hueston transposition, fingertip, 119 (IGAP) flap, 131
Hughes flap, eyelid, 42 Inferior orbital fissure, 22
Human bite wounds, 108 Inferior pedicle, reduction
Hydrocarbons, chemical burns, 151 mammoplasty, 133
Hydroxyapatite, 164 Inferior wall, eye, 29
Hyperdermis, 3 Inflammation, 1–2
Hypertrophic scars, 3 Inflammatory and degenerative
Hypoglossal nerve (CNXII), 25t disorders, 109–111
Hyponychium, 94 Dupuytren’s disease, 109–111
Hypopharynx, reconstruction, 40 gout, 111
Hypothenar hammer syndrome, 85 tenosynovitis, 111
Hypothermia, frostbite, 156 Infraclavicular block, 18
Infraorbital peripheral nerve, 25t
I Inhalation injury
Ibuprofen, inflammation and, 2 avoid RSI for intubation, 150
ICP. See Intracranial pressure bronchoscopy, 149
IFN-alpha, infantile nebulized heparin and
hemangiomas, 160, 161 acetylcysteine, 149
IIRI. See Ischemia-induced oscillator, 150
reperfusion injury pulse oximetry, 149
IL-1, 3 volumetric diffusive
IL-2, 3 respiration, 150

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 Index 175
Injectable fillers, 164 L
Injection LABCN. See Lateral antebrachial
emergency cases, 108 cutaneous nerve
high risk amputation, 108 Lacerations, facial, 35–37
paint gun injuries, 108 Lacrimal bone, 28
Innervation Lacrimal glands, 30
cranial nerves, 24t–25t Lacrimal system, 30
ear, 31 Lambdoid classification,
lips, 33 craniosynostosis, 72–73
nose, 31 Lasers
peripheral nerves, 25t infantile hemangiomas, 160, 161
Intercarpal joint, 83 in plastic surgery, commonly
Interphalangeal joints, 88 used, 163t
Interpolation/island, rhomboid Lateral antebrachial cutaneous
flap, 7 nerve, 86
Intracranial pressure, Lateral arm flap, arc of rotation,
craniosynostosis and, 71 POC, max. size, source
Intravelar veloplasty, 69 vessels, sensory nerves, 9t
Intravenous regional block, 19 Lateral canthus, anatomy, 29
IPJs. See Interphalangeal joints Lateral crural strut, nose, 39
Ischemia-induced reperfusion Lateral facial cleft, 62
injury, 14 Lateral incisors, 32
Lateral pedicle, reduction
J mammoplasty, 133
Jeanne’s sign, 118 Lateral two lumbricals, 88t
Jessner’s solution, 164 Lateral wall, eye, 29
Joints, osteology, 83–84 Latham appliance, 67
Jones tests, facial fractures, 45 Latissimus dorsi flap, 38
skin paddle, POC, arc of rotation,
size, vessel, nerve, 12t
K LD flap, autologous breast
Kabuki syndrome, 75 reconstruction, 130
Kanavel’s sign, 107 Leeches, flap survival and, 15
Karapandzic flap, lips, 42 LeFort fractures, 51
Kasabach-Merritt Leg
syndrome, 160, 161 bony injury in, management, 144
Keloid scars, 3 trauma to, Gustilo
Ketorolac, inflammation and, 2 classification, 141
Kienböck’s disease, 110 Leukoplakia, 55
Kirschner wires (K-wires), hand Levator alae alaequae, labialis
and peripheral nerve, 99 superioros, 26t
Klippel-Trenaunay syndrome, 126 Levator palpebrae superioris, 27t
Klippel-Trenaunay-Weber Levator veli palatini muscle, 27t
syndrome, 162 Lidocaine, maximum dose, 19
Knee, soft tissue Ligamentous injury, thumb, 102–103
reconstruction, 142 Ligaments, hand and peripheral
KTP laser, 163t nerve, 88–89

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 176 Index
Lightning, electrical burns Maffucci syndrome, 112, 162
and, 150 Malar fracture, 46
Limberg variant, rhomboid flap, 7 Malignant tumors of hand
Lingual, regional anesthesia, 17 and peripheral nerve, 112
Lingual peripheral nerve, 25t Mallet finger, 92
Lip adhesion, 67 Mammoplasty, reduction, 132–134
Liposuction, aesthetics, 139 Mandible, 22
Lips reconstruction, 40–41
aesthetic units, 32 Mandibular fractures
musculature, innervation, edentulous patients, 54
vasculature, 33 pediatric, 54
reconstruction, 41–42 presentation, diagnosis, 52
topography, 32 principles of management,
tumors, 60 52–53
Lister’s tubercle, 84 treatment, 52, 53–54
Lobster claw deformity, 122 Mandibular osteotomies, 79
Local anesthesia, types, signs of Mannerfelt lesion, 111
toxicity, maximum dose, 19 Marcus-Gunn pupil, 30
Local flaps, facial wounds, 37 Marfan syndrome, 2, 128
Longitudinal arrest, radial, Martin-Gruber anastomosis, hand
classification, 121 and peripheral nerve, 113
Lower extremity Masseter muscle flap, 37
ankle, 143 Masseter muscles, 22, 26t
distal 1/3 tibia, 143 Mastectomy flap necrosis, 131
fasciotomy, 142 Mastication, muscles of, 26t
foot, 143 Mastopexy
knee, 142 breast ptosis, 133–134
Mess score, 142t techniques, 134
middle 1/3 tibia, 142 Mattress, specialty, pressure
proximal 1/3 tibia, 142 ulcers and, 138
soft tissue reconstruction by Maxilla, 28
region, 142 Maxillary fractures
thigh, 142 anatomy, 50
trauma, 141 presentation, patterns,
Low median nerve palsy, 117 treatment, 51
Low ulnar nerve palsy, 117 Maxillary osteotomies, 79
Lymphatics, lips, 33 Maxillary sinuses, 21
Lymph node levels, for neck MCPJ. See Metacarpophalangeal
dissection, 28 joint
Medial antebrachial nerve, 86
M Medial canthus, anatomy, 29
Macrodactyly, Dell classification, 126 Medial pterygoid muscles, 22
Macrostrain, sponge dressing Medial two lumbricals, 88t
and, 4 Medial wall, eye, 29
Madelung deformity, 122 Median, regional anesthesia, 18
Mafenide acetate, for burn Median and ulnar nerve palsy,
patients, 148t combined, 118

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 Index 177
Median facial cleft syndrome, 74 Midfacial defects, complex,
Median nerve, 86 reconstruction, 41
compression neuropathies, Miosis, 30
115–116 Mirror hand, 125
lesions, 117 Moberg, thumb, 119
Meibomian glands, 30 Möbius syndrome, 60, 75
Meissner’s corpuscle, 113 Modified Kessler technique, 91
Melanoma, 158–159 Modified radical neck
staging, 158–159 dissection, 57
treatment, 159 Mohs surgery, basal cell
types, 158 carcinoma, 157
Mental peripheral nerve, 25t Molars, 32
Merkel cell, 113 Moll, 30
Mess score, 142t Motrin, inflammation and, 2
Metacarpal fractures, 99 MRND. See Modified radical
base fx, 99 neck dissection
closed management, 99 Muscles
diaphyseal fx, 99 eyelid, 29
isolated metacarpal neck/shaft hand and arm, 87t–89t
fx, 99 head and neck, 26t–27t
thumb metacarpal fx, 100 lips, 33
Metacarpals, osteology, 83 Musculocutaneous flaps, 38
Metacarpophalangeal joint, 83, 88 Musculocutaneous nerve, 86
fractures, dorsal, simple and Musculocutaneous pedicle, 8t
complex, 104 Musculus uvulae muscle, 27t
Metopic classification, Mylohyoid muscle, 26t
craniosynostosis, 72
Microstrain, sponge dressing N
and, 4 Nager syndrome (acrofacial
Microsurgery dysostosis), 75
anastomoses, 13 NAM. See Nasoalveolar molding
planning, 13 Naproxen, inflammation and, 2
Microtia, 76–77 Nasal approach
classification, 76 closed, 34
hearing defects associated open, 34
with, 76 Nasal fractures, presentation and
surgical reconstruction, treatment, 49
76–77 Nasal lobule, components, 38
Middle phalanx fractures Nasoalveolar molding, 67
closed management, 101 Nasofrontal recess, 21
displaced a/o articular, 101 Nasolabial flap, 37
dorsal fx subluxation of PIP, 101 NCS. See Nerve conduction studies
extremely disabling, Neck reconstruction, burn wound
comminuted, unstable fx-tx management, 154
options, 101 Neomycin, for burn patients, 149t
nondisplaced, extra Nerve conduction studies, 114
articular, 101 Nerve grafts, 4

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 178 Index
Neurapraxia, Sunderland, Ophthalmologist, burn wound
lesion, usual course, evaluation and, 153
management, 114t Optic canal, 22
Neurilemmoma, hand and peripheral Optic nerve (CNII), 24t
nerve, 112 Oral cavity, 32
Neurofibromas, hand and peripheral cancer, staging, 56, 56t
nerve, 112 reconstruction, 40
Neurogenic tumors, hand, 112 Oral fluid management guidelines,
Neurotmesis, Sunderland, for burn patients, 147t
lesion, usual course, Oral-ocular clefts, 62
management, 114t Orbicularis oculi muscle, 26t, 29
NFR. See Nasofrontal recess Orbicularis oris muscle, 27t
Nipple reconstruction, 132 Orbit, eye, 28
Nitroglycerin paste, flap survival Orbital fractures
and, 15 anatomy, mechanism of injury,
NOE fractures treatment, 46
anatomy, presentation, blow-in fractures, 48
classification, 49 complications, 49
exposure to NOE complex, 50 orbital roof fractures, 48
treatment, complications, 50 timing, surgical approach,
Nonsteroidal anti-inflammatory materials, 48
drugs, inflammation and, 2 Orbital septum, anatomy, 29
Nose Orbitozygomatic (OZM) fracture, 46
Ala, 39 Oronasal clefts, 61–62
general rules, 38 Oropharyngeal tumors, 55–57
lacerations, 36 adjuvant therapy, 57
nine aesthetic subunits, 38 complications, 57
nonanatomic cartilage grafts, 39 etiology, location, diagnosis, 55
support, 39 local recurrence and surgical
support, soft tissue envelope, margins, 57
vasculature, innervation, 31 surgical therapy, 56–57
tip, 39 treatment, 56
NSAIDs. See Nonsteroidal Oropharynx, muscles of, 27t
anti-inflammatory drugs Orthognathic surgery, 78–79
Nutrition, burn patients and, 146 angle classification, 78–79
definition, 78
O points and angles, 78
Oblique fracture, 98 procedures, 79
Occupational therapy, burn wounds, transverse maxillary
late reconstruction, 154 deficiency, 79
Ocular issues, burn wounds, 153 Osler-Weber-Rendu disease, 162
Oculomotor nerve (CNIII), 24t Osteoarthritis, 110
Olfactory nerve (CNI), 24t Osteoblastoma, hand, 113
Ollier’s syndrome, 112 Osteoid osteoma, phalanges, 113
Oncocytoma, 58 Osteology, head and neck, 21–22
Online Mendelian Inheritance in face, 21
Man website, 74 fissures and foramina, 22

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 Index 179
mandible, 22 rotation, size, vessel,
sinuses, 21 nerve, 12t
vault, 21 Pediatric mandible fractures, 54
Ovarian cancer, palmar fibromatosis Pedicled flaps, 120
in females and, 109 autologous breast
Oxandrolone, 145 reconstruction, 130
Pedicles, reduction
P mammoplasty, 133
Pacinian corpuscle, 113 Penile flap, arc of rotation, POC,
Pairolero classification, sternotomy max. size, source vessels,
infections, 137 sensory nerves, 10t
Palatal anatomy, 32 Periareolar approach, breast
Palate fracture, 51 augmentation, 134
Palatine bone, 28 Perineum, 138
Palatoglossus muscle, 27t Periorbital surgical approach, 33
Palatopharyngeus muscle, 27t supraorbital eyebrow, 33–34
Palmar fibromatosis, in females transconjunctival, 33
and ovarian cancer, 109 transcutaneous, 33
Palmar interossei, 88t Peripheral nerves
Panfacial fractures brachial plexus, 85–86
goals of reconstruction, 51 diagnosis, 114–115
treatment, 52 head and neck, 25t
Papillary dermis, 3 nerve injury, 113
Paramedian forehead flap, arc summary of, 114t
of rotation, POC, max. repair, 115
size, source vessels, structure, 113
sensory nerves, 9t Pfeiffer’s syndrome, 74, 127
Parkes Weber syndrome, 162 Phalangeal fractures, 98
Parkland formula, burns and, Pharyngeal flap, 69
145, 146 Phenol chemical peel, 164
Paronychia, hand, 107 Phocomelia, 121
Paronychium, fingernails, 94 Physical therapy, burn wounds,
Parotid duct, lacerations, 37 late reconstruction, 154
Parotidectomy, 59 Pierre Robin sequence, 65, 75
Parotid glands, 28 Pisiform, 84
tumors, 58–60 Platelet-derived growth factor, 3
benign and malignant, 58 Plates, hand and peripheral
complications, 59–60 nerve, 98
diagnosis, 59 Platysma muscle, 26t
surgery, 59 Plavix, coagulation and, 1
Patterson classification, congenital Pleomorphic adenomas, 58
constriction band Pletal, coagulation and, 1
syndrome, 127 PMRT. See Postmastectomy
PDGF. See Platelet-derived radiation therapy
growth factor Poland’s syndrome, 123, 127
Pectoralis major flap, skin Polydactyly, Wassel
paddle, POC, arc of classification, 125

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 180 Index
Polyethylene implants, orbital Pterygoid (medial) muscle, 26t
fractures, 48 Ptosis
Polymyco, for burn patients, 149t breast, 133
Polymyxin B, for burn lid, 30
patients, 149t Pulley dilation, 91
Port wine stains, 161 Pulsed dye laser, 163t
Postauricular flap Pupillary function, 30
arc of rotation, POC, max. size,
source vessels, sensory Q
nerves, 9t Q-switched alexandrite, 163t
ear, 43 Q-switched ruby laser, 163t
Posterior interosseous artery
flap, 120 R
Posterior interosseous flap, arc of Radial, regional anesthesia, 18
rotation, POC, max. size, Radial angulation, 97
source vessels, sensory Radial artery, vascular
nerves, 9t supply, 84–85
Postmastectomy radiation Radial forearm flap, 38
therapy, 130 arc of rotation, POC, max. size,
Prednisone, infantile source vessels, sensory
hemangiomas, 161 nerves, 8t
Prefabricated flaps, 13 Radial nerve, 86
Preiser disease, 110 compression neuropathies, 116
Prelaminated flaps, 13 palsy, 119
Preseptal muscle, 29 Radial styloid, 84
Pressure ulcers, etiology and Radiation therapy,
epidemiology, staging, postmastectomy, 130
management, by site, 138 Radical neck dissection, oral
Primary palate, 32 cancer, 56
Proliferation, 2 Radiesse, 164
Pronator quadratus, 87t Radiocarpal joint, 83
Pronator syndrome, clinical Radiography
symptoms, 115–116 facial fractures, 44
Pronator teres, 87t hand and peripheral
Propeller flap nerve, 96–98
distal 1/3 tibia, 143 Radiology, mandibular
middle 1/3 tibia, 142 fractures, 52
Prostacyclin, 1 Radiotherapy, oral cancer, 57
Proteus syndrome, 126 Rectus abdominus flap, 38
Proximal phalanx fractures skin paddle, POC, arc of
closed management, rotation, size, vessel,
100–101 nerve, 11t
diaphyseal, 101 Rectus femoris flap, skin paddle,
periarticular (MCPJ), 101 POC, arc of rotation, size,
periarticular (PIP), 101 vessel, nerve, 11t
Pseudoptosis, breast, 133 Recurrent laryngeal peripheral
Pterygoid (lateral) muscle, 26t nerve, 25t

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 Index 181
Reduction, fixation, and Remodeling, 2
immobilization Replantation, 103
hand and peripheral Restylane, 164
nerve, 96–107 Reticular dermis, 3
carpal, 104–106 Retromandibular approach, 35
carpal instabilities and fracture Retropharyngeal space, 22
dislocations, 106–107 Reversed flap, 13
dislocations, 103–104 Reversed superficial sural flap,
distal phalanx, 101–102 arc of rotation, POC,
general principles, 98–99 max. size, source vessels,
ligamentous injury, 102–103 sensory nerves, 8t
MCPJ, 104 Reverse Gillies’ maneuver, zygoma
metacarpal fractures, 99–100 fractures, 46
middle phalanx, 101 Reverse radial forearm flap, 120
proximal phalanx, 100–101 Rheumatoid arthritis
replantation, 103 IP joints, 111
Reduction and Association of the MCP joint, 111
Scaphoid and Lunate operative, 110
(RASL) procedure, 107 tendons, 111
Reduction mammoplasty, thumb, 111
132–134 treatment, 110
average measurements, 132 wrist, 111
complications and curve Rhinoplasty, 79–80
balls, 133 aging, 80
indications, 132 male, 80
mastopexy, 133–134 nasal anatomy, 79
preoperative evaluation operative, 80
and preparation, 133 Rhomboid flap, 6, 7
risk factors for need for free Rhytidectomy, 34, 80
nipple graft, 132 Riche-Cannieu anastomosis,
risks, 132 hand and peripheral
techniques, 133 nerve, 113
tuberous breasts, 134 Risdon approach, 34
Regional anesthesia, 17–19 Risorius muscle, 27t
brachial plexus, 18 RND. See Radical neck dissection
buccal, 18 Roberts’ views, 97
digital block, 18–19 Robert syndrome, 121
greater palatine, 17 Romberg disease (progressive
head and neck, 17 hemifacial atrophy), 75
inferior alveolar, 17 Rotation flap, 5
lingual, 17
nasopalatine, 17 S
wrist block, 18 Saethre-Chotzen syndrome, 73–74
Regional flaps, large defects of Sagittal classification,
hand/digits, 120 craniosynostosis, 71
Regnault grading, breast Saline, breast implant, 134
ptosis, 133 Salivary glands, 28

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 182 Index
Salivary gland tumors, 58–60 Singapore flap, 138
Sartorius flap, skin paddle, POC, Sinuses, 21
arc of rotation, size, vessel, Skate flap, nipple and areolar
nerve, 12t reconstruction, 132
Scalp, 32 Skin, anatomy of, 3
lacerations, 36 Skin cancer, basal cell
Scaphoid fractures carcinoma, 157
approaches and surgical Skin grafting, nipple and areolar
principles, 106 reconstruction, 132
complications, 106 Skin grafts, 4
diagnosis, 104 Skull base, foramina, 22
general principles, 105 Slow-flow vascular
radiographs, 104–105 malformations, 161
Scaphoid tubercle, 84 SND. See Selective neck dissection
Scapholunate instability, 106 Sodium hypochlorite, for burn
acute, 107 patients, 149t
chronic, 107 Sodium levels, burn patients and, 146
physical findings, 107 Soft palate, reconstruction, 40
scapholunate angle, 106 Soft tissue reconstruction,
tear of scapholunate 34–44, 119–121
ligament, 106 complex midfacial defects, 41
Scapular/parascapular flaps, arc ear, 43–44
of rotation, POC, max. eyelid, 42–43
size, source vessels, facial wounds, 35–38
sensory nerves, 9t fingertip, 119–121
Scars, 3 lips, 41–42
Schirmer’s test, 30, 81 lower extremity, by region, 142
Screws, hand and peripheral mandible, 40–41
nerve, 98 nose, 38–39
Sculptra, 164 oral cavity, 40
Secondary palate, 32 Soft tissue tumors, hand
Selective neck dissection, 57 and peripheral nerve
SEPA flap, arc of rotation, POC, benign, 111–112
max. size, source vessels, giant-cell tumor of tendon
sensory nerves, 10t sheath, 112
Septic joint, 108 glomus tumor, 112
Septocutaneous pedicle, 8t malignant, 112
Serratus anterior flap, skin paddle, neurogenic tumors, 112
POC, arc of rotation, size, Soleus, soft tissue
vessel, nerve, 12t reconstruction, 142
Silicone, breast imlplant, 134 Soleus flap, skin paddle, POC, arc
Silvadene, for burn patients, 148t of rotation, size, vessel,
Silvamyco, for burn patients, 148t nerve, 11t
Silver nitrate, for burn Sphenoid bone, 28
patients, 148t Sphenoid sinuses, 21
Silver sulfadiazine, for burn Sphincteroplasty, 69
patients, 148t Spinal accessory nerve (CNXI), 25t

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 Index 183
Spiral fracture, 98 Superior pharyngeal constrictor
Split-thickness skin graft, 121 muscle, 27t
Sponge dressing, 4 Superior wall, eye, 29
Spreader graft, nose, 39 Superoxide dismutase, flap survival
Squamous cell carcinoma and, 15
oral, 57 Supinator muscles, 87t
risk and treatment, 158 Support stockings, for vascular
Stabilization, mandibular malformations, 162
fractures, 52, 53 Supraclavicular block, 18
Star flap, nipple and areolar Surgical approaches, 33–35
reconstruction, 132 coronal, 34
Stensen’s duct, 58 nasal, 35
Sternotomy infections, Pairolero periorbital, 33–34
classification, 137 TMJ: preauricular
Steroids incision, 35
infantile hemangiomas, 161 transfacial mandible, 34–35
intralesional injection, for transoral, 34
Dupuytren’s disease, 109 Surgical debridement, of necrotic
Stickler syndrome, 65 to healthy tissue, 4
Streptokinase, flap survival Suturing, 4
and, 15 Symbrachydactyly, 127
STSG. See Split-thickness Syndactyly
skin graft anatomy, classification, 123
Sturge-Weber syndrome, 161 surgery, 124
Subcondylar fracture, Syndromic clefts, 65
treatment, 53
Sublingual salivary glands, 28 T
Sublingual space, 22 Tajima, 92
Submandibular (Risdon) Tarsus, eyelid, 29
approach, 34 TAR syndrome, 128
Submandibular salivary Tattoo, areolar, 132
glands, 28 Tavernier’s method, 103
Submandibular space, 23 Tear glands, 30
Submental space, 22 Teeth, 32
Submucous cleft palate, 66 Temporalis muscle, 26t
Sulfamylon, for burn patients, 148t Temporaparietal fascia flap, arc
Superficial temporal artery fascial of rotation, POC, max.
flap, 37 size, source vessels,
Superior gluteal artery perforator sensory nerves, 9t
(SGAP) flap, 131 Tendon retrieval, 91
Superior laryngeal peripheral Tendons
nerve, 25t extensor, 92–94
Superior medial pedicle, reduction flexor, 90–92
mammoplasty, 133 Tendon sheath infection
Superior orbital fissure, 22 (tenosynovitis)
Superior pedicle, reduction acute, 107–108
mammoplasty, 133 chronic, 108

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 184 Index
Tendon transfers physical evaluation, 96t
principles and factors radiography, 97
in selection, 116–117 trigger, congenital, 128
specific lesions, 117–119 Tibia, soft tissue reconstruction,
Tenosynovectomy, 111 142–143
Tenosynovitis. See Tendon sheath Tibialis anterior flap, skin paddle,
infection (tenosynovitis) POC, arc of rotation, size,
Tensor fascia lata flap, skin paddle, vessel, nerve, 12t
POC, arc of rotation, size, Tinel’s sign, over cubital tunnel, 116
vessel, nerve, 11t TMJ: (preauricular incision), 34
Tensor veli palatini muscle, 27t TMJ reconstruction, 40–41
Tenzel flap, eyelid, 42 TNM staging, for oral cavity
Terry Thomas sign, 106 cancer, 56, 56t
Tessier clefts, 61 Tongue
Tetanus status, facial wounds, 35 lacerations, 36
Tetraphocomelia, 121 reconstruction, 40
Thermal burns Toradol, inflammation and, 2
immediate wound Total lip defect, 42
considerations, 147–148 Tourniquet, hand and peripheral
infection, 148 nerve, 128
initial patient TRAM flap, autologous breast
considerations, 147 reconstruction, 131
scald injuries, 148 Transfacial mandible approach,
Thigh, soft tissue 34–35
reconstruction, 142 Transoral surgical approach
Thoracodorsal nerve, 86 mandible, 34
Thrombolytics, flap survival and, 15 maxilla, 34
Thumb Transumbilical breast
duplications, 125 augmentation, 134
hypoplasia, Blauth Transverse arrest, hand and
classification, 122 peripheral nerve, 121
inability to flex (FPL deficit), 117 Transverse fracture, 98
IP Transverse myocutaneous gracilis
muscle, origin/insertion, (TMG) flap, 131
nerve, root, 89t Trapezium, 83
physical evaluation, 96t Trauma
ligamentous injury, 102–103 facial fractures, 44–46
MCP mandibular fractures, 52–54
muscle, origin/insertion, maxillary fractures, 50–51
nerve, root, 89t nasal fractures, 49
physical evaluation, 96t NOE fractures, 49–50
metacarpal fx, 100 orbital fractures, 47–49
base, 100 panfacial fractures, 51–52
diaphyseal, 100 zygoma fractures, 46–47
Moberg flap, 119 Treacher Collins syndrome
muscle, origin/insertion, nerve, (mandibulofacial
root, 89t dysostosis), 63, 75, 128

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 Index 185
Triamcinolone, infantile VACTERL, 128
hemangiomas, 161 Vagina, 138
Triceps, 87t Vagus nerve (CNX), 25t
Trigeminal nerve (CNV), 24t Van der Woude syndrome (lip-pit
Trochlear nerve (CNIV), 24t syndrome), 65, 75
Trunk, burn wound management, 155 Vascular anomalies, infantile
TUBA. See Transumbilical hemangiomas, 159–161
breast augmentation Vascular endothelial growth
Tubed pedicle flap, ear, 43 factor, 3
Tuberous breasts, 134 Vascular malformations,
Tumors classifications, 161–162
hand and peripheral nerve combined, 162
bony, 112–113 fast-flow, arteriovenous, 162
general, 111 slow-flow
peripheral nerves and tendon capillary, 161
transfers, 113–119 lymphatic, 161–162
soft tissue, 111–112 Vascular supply
head and neck, 55–61 brachial artery, 84
ameloblastoma, 60 radial artery, 84–85
epidemiology, 55 ulnar artery, 85
facial nerve palsy, 60 Vasculature
lip tumors, 60 ear, 31
oropharyngeal tumors, 55–57 eyelid, 29
salivary gland tumors, 58–60 head and neck, 23
lips, 33
U nose, 31
Ulnar, regional anesthesia, 18 VEGF. See Vascular endothelial
Ulnar artery, vascular supply, 85 growth factor
Ulnar artery island flap, 120 Velocardiofacial syndrome, 65, 76
Ulnar collateral ligament Velopharyngeal incompetence, 69
rupture, 102 Vermillion, 32
Ulnar deficiency, 122 Vermillion deficiency, 41
Ulnar dimelia, 125 Vertical buttress, NOE fractures, 49
Ulnar nerve, 86 Vertical skin pattern, reduction
compression neuropathies, 116 mammoplasty, 133
lesions Virchow’s law, 70
diagnosis, 117 Volar nerve block, 18
treatment, 117 Volar plate, 90
Ulnar variance, 97 Volkmann’s ischemic
Unicoronal classification, contracture, 116
craniosynostosis, 71–72 von Hippel-Landau syndrome, 162
Urine, burns and, 146 von Willebrand factor (vWF),
Urokinase, flap survival and, 15 coagulation and, 1
von Willebrand’s disease, 1
V VPI. See Velopharyngeal
VAC (negative pressure ) incompetence
dressing, 4 V-Y advancement flap, 5

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 186 Index
W VAC (negative pressure)
Wallace, A. B., 147 dressing, 4
Wallace’s rule of nine, for wet to dry, 4
second- and third-degree Wound healing
burns, 147 anatomy of skin, 3
Walls, eye, 29 coagulation, 1
Wartenberg’s sign, 117 contraction/remodeling, 2
Wartenberg’s syndrome, 116 inflammation, 1–2
Warthin’s tumors, 58 phases of, 1–3
Wassel classification, proliferation, 2
polydactyly, 125 scars, 3
Webster-Bernard flap, lips, 42 substrates, 2–3
Wedge resection, ear, 43 W-plasty, 6
Weight loss patients (massive), Wrist
aesthetics, 139 muscle, origin/insertion, nerve,
Wet to dry wound care, 4 root, 87t
White phosphorus, chemical physical evaluation, 95t
burns, 151 radiography, standard and
Whitnall’s tubercle, 29 scaphoid view, 97
Wide localized excision, breast Wrist block, 18
reconstruction, 130
Wise pattern, reduction X
mammoplasty, 133 Xeroderma pigmentosum, 157
WLE. See Wide localized excision Xiaflex, for Dupuytren’s
Workhorse regional fasciocutaneous disease, 109
flaps, 8t–10t
Wound care and coverage
principles, 4–17 Z
flaps, 4, 7–13 Zancolli lasso, 118
physiology, 13–14 Zeiss, 30
grafts, 4 Zone of polarizing activity
managing perfusion (ZPA), 121
problems, 16–17 Z-plasty, angles of, 6, 6
microsurgery, 13 Zygoma, 28
monitoring flap viability, 16 Zygoma fractures
optimizing flap survival, 15 complications, 47
perfusion issues, 15–16 management, 46–47
surgical debridement of necrotic presentation, 46
to healthy tissue, 4 Zygomaticomaxillary complex (ZMC)
suturing, 4 fracture, 46

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