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Surgery_Schwartz. nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring defects, be they congenital, traumatic, or functional.This strong thread of advances in reconstructive surgery continues even today. What does seem under-recognized is that the clinical practice of plastic and reconstructive surgery touches on every other area of surgery. Enhanced reconstructive capabilities strengthen all other specialties significantly, such as the ability to safely perform radical cancer operations, sal-vage traumatic limbs, or extend the reach of neonatal medicine by congenital reconstruction. Each surgical specialty encoun-ters problems that might be addressed by some form of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and


Surgery_Schwartz

Surgery_Schwartz. of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and function. One of the most powerful examples of this response is the advances that occurred as a result of World Wars I and II. Walter Yeo, a sailor injured at the Battle of Jutland, is assumed to have received plastic surgery in 1917. The photograph shows him before (Fig. 45-3, left) and after (right) receiving a flap surgery performed by Gillies.The Gulf war and the conflicts in the Middle East have prompted several revolutionary reconstructive surgical advances in limb salvage, microsurgery, supermicrosurgery, hand, face, and abdominal wall transplantation. Plastic surgeons have also targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example,


Surgery_Schwartz

Surgery_Schwartz. targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example, neurosurgeons at times must replace or stabilize bone in the cranium or spine, and healthy soft tissue coverage is essen-tial for optimal healing. Head and neck surgeons face tissue replacement problems in order to restore normal function and appearance after major tumor ablation. Thoracic surgeons must manage bronchopleural fistulae, esophageal defects, or loss of chest wall integrity after trauma or tumor resection. Cardiolo-gists and cardiac surgeons at times face complicated wound Introduction 1967Purpose 1969General Principles 1969Skin Incisions / 1969Incision Repair / 1970Wound Healing / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial


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Surgery_Schwartz. / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial Anomalies / 1981Reconstructive Surgery in Adults 2001Maxillofacial injuries and Fractures / 2002Mandible Fractures / 2002Frontal Sinus Fractures / 2003Orbital Fractures / 2004Zygomaticomaxillary Complex Fractures / 2004Nasoorbitalethmoid and Panfacial Fractures / 2005Posttraumatic Extremity Reconstruction / 2005Oncologic Reconstructive Surgery / 2008Breast Reconstruction / 2009Oncoplastic Breast Reconstruction / 2009Implant-based Reconstruction / 2009Tissue Flaps and Breast Implants / 2010Autologous Tissue Reconstruction / 2010Accessory Procedures / 2011Trunk and Abdominal Reconstruction / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of


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Surgery_Schwartz. / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of the Body / 2018Suction Lipectomy / 2022Autologous Fat Grafting / 2024Brunicardi_Ch45_p1967-p2026.indd 196701/03/19 6:26 PM 1968Figure 45-1. The Edwin Smith papyrus (Egypt, 1600 b.c.).Figure 45-2. Statue of Shushruta, considered the “founding father of surgery” in India.Key Points1 It is critical to understand the physiologic basis and ratio-nale of wound healing in order to further assimilate surgi-cal and nonsurgical care of wounds and methods of wound care.2 Understanding the reconstructive choices in tissue repair cases is critical for any surgeon. The principles of soft tis-sue and skin repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical,


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Surgery_Schwartz. repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical, and social needs. Coordinated, interdisciplinary team care is crucial to success.4 Robin sequence, characterized by micrognathia, glossop-tosis, and airway obstruction, can be managed with prone positioning, tongue-lip adhesion, mandibular distraction osteogenesis, or tracheostomy.5 The first-line treatment for high-risk hemangiomas is oral propranolol, which can induce rapid involution and has a more favorable side effect profile than systemic steroids.6 The coordination of care for patients in a trauma depart-ment is an important part of a surgeon’s role, whether that role be as a trauma emergency department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the


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Surgery_Schwartz. department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the appropriate triage of reconstructive procedures. As a leader in a trauma bay of the trauma service, the surgeon typically assumes a cap-tain’s role in decision-making.8 Principles of oncologic reconstruction have evolved sig-nificantly, and a deeper understanding of these reconstruc-tive choices is essential for a surgeon who is often the first point of contact for cancer patients and responsible for making critical referrals.9 The combined work of general surgeons and reconstruc-tive plastic surgeons has revolutionized the care of abdom-inal wall defects, including ventral hernias, repair after tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their


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Surgery_Schwartz. tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their etiology and the recon-structive options that are available to these patients.infections, sternal osteomyelitis, or failure of soft tissue cov-erage that leads to exposure and contamination of implanted devices such as left ventricular assist devices or cardiac pace-makers. Orthopedic surgeons managing segmental bone defects in the extremities at times require replacement by surgical transfer of vascularized bone segments rather than conventional bone grafts or alloplastic substitutes. Urologists, colorectal sur-geons, and gynecologists who commonly perform surgery in the perineum encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive


Surgery_Schwartz

Surgery_Schwartz. encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive surgeons.Plastic and reconstructive surgery is field characterized by innovation, and it has yielded important contributions to other surgical specialties. These include notable advances in hand and upper extremity surgery, craniofacial surgery, peripheral nerve surgery, and reconstructive microsurgery. Entirely new fields of have emerged from plastic surgery research. Joseph E. Murray, a Boston plastic surgeon, and his team performed the first renal transplantation procedures and laid the foundation for modern organ transplantation, an achievement for which he was awarded the Nobel Prize in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell


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Surgery_Schwartz. in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell transplantation, regenerative medicine, computer-assisted surgical planning, medical appli-cation of three-dimensional manufacturing methods, infection control, and outcomes research. Plastic and reconstructive sur-gery is a vibrant field that brings tremendous value to people’s health and quality of life through life-changing reconstructive, restorative, and transformative surgeries.Brunicardi_Ch45_p1967-p2026.indd 196801/03/19 6:26 PM 1969PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-3. Walter Yeo, a sailor injured at the Battle of Jutland in 1917.Figure 45-4. Joseph E. Murray, MD, awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery,


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Surgery_Schwartz. awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery, and to provide current examples of practice. Studying this chapter will help the reader to understand (a) the principles of plastic surgery that translate into other surgi-cal specialties; (b) the kind of clinical problems that may be addressed using plastic surgery techniques; and (c) the types of research found in plastic and reconstructive surgery. It will make clearer the nature of the field and its role in the multidis-ciplinary care environment of modern healthcare.GENERAL PRINCIPLESGeneral principles of plastic surgery relate to technical aspects of incision planning and wound repair. These principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of


Surgery_Schwartz

Surgery_Schwartz. principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of skin, which is completely justified; however, over the past few years plastic surgical focus has expanded to include the entire integument. Muscles, fascia, fat, skeletal framework, nerves, vascular net-works, and their dynamic interactions have become far more important factors that are choreographed in most reconstructive processes.Skin IncisionsFrom a surgical viewpoint, the skin is a multilayered tissue formed by dermis and epidermis. It is the largest organ in the human body and exists in a state of dynamic equilibrium from the balance of tension created by external and internal factors. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch


Surgery_Schwartz

Surgery_Schwartz. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch architecture upon removal of the stretch. The dermis is com-posed of different types of collagen and elastic protein fibers (elastin), and epidermis, composed primarily of cells anchored together in various stages of maturation. The skin serves impor-tant functions of thermoregulation, affording tactile sensation, and protection from foreign materials and microorganisms. Areas of skin exposed to view in normal clothing play a sig-nificant role in personal appearance and social interaction. As a result, even favorable scars from surgical incisions can have an undesirable effect on personal appearance. Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of


Surgery_Schwartz

Surgery_Schwartz. Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of tension caused by gravity and its conformation over underlying structures between sites that are tethered by subcutaneous fibrous tissue, which secure the deep surface of the dermis to underlying points of fixation. When the skin is incised linearly, the wound edges separate in a predicable fashion forming an ellipse with the long axis perpendicular to the lines of greatest tension. These tension lines are often called “Langer’s lines,” after Carl Langer, a 19th century anatomist from Vienna who first described them based on studies in fresh cadavers (Fig. 45-5). Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because


Surgery_Schwartz

Surgery_Schwartz. tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because the skin often has natural wrinkles following these lines and there is less tension perpendicular to the orien-tation of the wound1 (Fig. 45-6). Based on these principles,2 a recommended pattern for incisions can be made (Fig. 45-7).Using the proper technique for creating and repairing skin incisions ensures uncomplicated wound healing with few distorting surface scars. The epidermis and superficial dermis should be incised sharply with a scalpel. The incision is then continued through the deep dermis and subdermal plexus of blood vessels with electrocautery. This technique helps to mini-mize collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the


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Surgery_Schwartz. collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the surface of the skin in order to facilitate accurate reap-proximation during wound closure. As the incision is deepened through the subcutaneous tissue to expose underlying structures, it is important to avoid creating multiple pathways through the tissue, which can create focal areas of devitalized tissue that form a nidus of infection or lead to delayed wound healing. The Brunicardi_Ch45_p1967-p2026.indd 196901/03/19 6:26 PM 1970SPECIFIC CONSIDERATIONSPART IIFigure 45-5. “Langer’s lines,” named after Carl Langer, a 19th century anatomist from Vienna.Figure 45-6. Lines of relaxed skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or


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Surgery_Schwartz. skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or electrocau-tery in order to reach the deeper structures.Traumatic wounds do not permit the same careful plan-ning that is possible with incisions made in undamaged skin. Nevertheless, optimum repair of traumatic lacerations involves similar principles applicable in nontraumatic circumstances. The surgeon must remove as much traumatized tissue as pos-sible from the wound edges, converting the uncontrolled trau-matic wound into a controlled surgical wound. All devitalized tissue is excised. The same principles of making incisions perpendicular to the skin surface and avoiding creating mul-tiple pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this


Surgery_Schwartz

Surgery_Schwartz. pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this reorientation, and they often involve creating small local flaps of undamaged tissue using geometric tissue rearrangements. These techniques will be considered later in this chapter. Following these principles increases the likelihood of uncomplicated wound healing and reduces the need for later treatment of unfavorable scars. However, there are situations in which the direction of the incision has been preestablished, as in acute lacerations, burns, or old contracted and distorting scars. In these circumstances, the principles of proper incision placement can be combined with simple surgical techniques to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the


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Surgery_Schwartz. to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the scar when making the skin incision and not simply make the incision through the old scar. Closing scarred wound edges increases the likelihood of delayed wound healing, infections, and unfavorable new scars. It only takes a few moments to make the skin incision outside of the area of scarring through unscarred skin. Once the skin incisions on each side of the previous scar reach into the subcutaneous tissue, then the surface scar can be removed completely at the subder-mal level. This approach ensures that the final repair relies on undamaged tissues, thus facilitating uncomplicated healing and lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is


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Surgery_Schwartz. lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is characterized by excessive amount of collagen Brunicardi_Ch45_p1967-p2026.indd 197001/03/19 6:26 PM 1971PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45deposition,4 leading to hypertrophic scarring or keloid formation (Fig. 45-8). The difference between them is that a hypertrophic scar stops growing 6 months after the injury, whereas a keloid continues to grow, even growing well beyond its borders. Accu-rate approximation and stabilization of the skin edges helps to minimize the amount of collagen deposition required for skin healing. The most important layer to approximate is the dermis because this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal


Surgery_Schwartz

Surgery_Schwartz. this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal sutures followed by superficial sutures that incorpo-rated the upper layers of the dermis and epidermis. Absorbable deep dermal sutures have the advantage of disappearing over time; however, they can promote prolonged inflammation dur-ing this process. Nonabsorbable sutures minimize inflammation and might be indicated in individuals who are particularly prone to scar formation. A step-off between each side of the wound should be avoided because an uneven surface on each side of the wound can cause a shadow that accentuates the presence of the scar. Stability between the two wound edges is important because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of


Surgery_Schwartz

Surgery_Schwartz. because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of suture placed in the superficial closure. Sutures placed at the surface that go deep into the dermis can leave addi-tional scarring at the entry and exit points of the suture mate-rial in addition to the incisional scar. Sutures like this should be removed within the first week. If the superficial sutures are placed more shallowly in the dermis, there is a reduced tendency to form additional scarring. A subcuticular suture may be used instead of simple sutures. This type of technique avoids the risk of additional scarring along the wound edge; however, it can be more difficult to accurately reapproximate the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting


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Surgery_Schwartz. the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting for 85% of these events. The annual cost of this problem is estimated to be as high as $25 billion for hospital admissions, antibiotics, and local wound care.3Normal wound healing is achieved through four highly choreographed, overlapping biophysiologic phases: hemostasis, inflammation, proliferation, and tissue remodeling or resolu-tion. Each phase initiates a cascading set of processes critical to the desired result of a healed wound.1Figure 45-8. Hypertrophic scar (left) and keloid (right).Figure 45-9. Phases of wound healing.Hypertrophic ScarKeloidBlood clotBlood vesselScabFibroblastFibroblastsproliferatingFreshlyhealedepidermisFreshlyhealeddermisMacrophageSubcutaneousfatBleedingInflammatoryProliferativeRemodelingSeveral factors impede wound healing and need to be understood so that they can be


Surgery_Schwartz

Surgery_Schwartz. factors impede wound healing and need to be understood so that they can be mitigated. Successful mitiga-tion of these adverse factors requires precise, least-traumatic surgical technique that incorporates new methods of prevention and treatment of infection and an understanding of the role of microbial behavior, including the formation of biofilm. Because chronic diseases such as diabetes, vascular insufficiency, and obesity are on the rise, there must be a better understanding of chronic versus acute wounds and how comorbid conditions affect wound healing. Lastly, the impact of age, gender, and nutrition becomes more important as the population of aging patients increases.Phases of Wound HealingThere are different processes that characterize healing in sev-eral types of tissue, such as skin, muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that


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Surgery_Schwartz. muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that overlap: (a) bleeding and hemostasis, (b) inflammation, (c) proliferation, and (d) tissue modeling or resolution (Fig. 45-9).These processes occur in sequence over a 1-year duration, but they also significantly overlap and work in terms of a “con-tinuum of processes” rather than discrete “stop-and-go” phases. As shown in Fig. 45-9, each phase is characterized by several Brunicardi_Ch45_p1967-p2026.indd 197101/03/19 6:26 PM 1972SPECIFIC CONSIDERATIONSPART IIwell-defined processes that are dominated by cellular as well as noncellular elements, such as platelets, macrophages, and cyto-kines, that act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result


Surgery_Schwartz

Surgery_Schwartz. act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result in the formation of a clot. The extracellular matrix that supports the tissue framework and otherwise acts as a barrier is now open to the vascular compartment, resulting in the release of several factors into the wound. In addition, the release of proteins— otherwise stored within the extracellular matrix—and the presi-dent cells act as further stimulants that start the hemostatic pro-cess. Inflammatory plasma proteins and leukocytes also migrate into the wound. On the cellular level, the plasma membrane of each platelet contains several receptors for collagen (glycopro-tein 1A and 2A). Once these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation,


Surgery_Schwartz

Surgery_Schwartz. these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation, vasoconstriction, and the subse-quent activation of the clotting cascade. As these initial platelet activation factors are released, there is a subsequent push that influences angiogenesis inflammation. These systemic immune response platelet-derived factors include biologically active proteins, such as PDGF, TGF-β, and VEGF, as well as other cytokines, such as PF4 and CD40L.In addition to the release of these factors, the binding of selected proteins within the already developed fibroblasts and the combination of two elements within the extracellular matrix create a chemotactic gradient that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac


Surgery_Schwartz

Surgery_Schwartz. that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac surgery, and certain types of skin repair, where autologous platelet transfusions have shown to accelerate the healing process.The subsequent fate of the platelet plug is determined by the amount of circulating fibrinogen. The vascular system interacts with the sympathetic nervous system by eliciting vasoconstriction from the actions of cytokines, prostaglandins, and catecholamines. There is also an alteration of capillary permeability caused by histaminic responses and the mediation of VEGF, which is released from micelles and the damaged endothelium. This highly interactive process results in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of


Surgery_Schwartz

Surgery_Schwartz. in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of wound healing and arguably overlaps the hemostatic face. Polymorphonuclear leu-kocytes (PMNs) and macrophages appear in the wound right after platelets, and their primary role is mainly to act as scav-engers. They clear the wound environment of debris, foreign material, bacteria, dead tissue cells and any other devitalized issues that would otherwise impede the healing process. Both macrophages and PMNs aid in phagocytosis and the secretion of free articles that kill bacteria and reduce the bioburden. Cel-lular migration into the wound is highly controlled by bioactive agents within the wound and within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also


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Surgery_Schwartz. within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also interact with the humoral system to facilitate the key functions of cell activation, recruitment, and proliferation, as well as migration from the intravascular compartment to the extracellular matrix. Within 48 hours of tissue injury, PMNs and macrophages are recruited to the wound in very large numbers, heralding the inflamma-tory response. As described in other chapters in this text, macro-phages possess a very large repertoire of functions, all of which are geared towards removing the nonviable elements in the wound and recruiting other cell types into the wound that facili-tate angiogenesis, fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species


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Surgery_Schwartz. fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species that result in cellular kill-ing specifically related towards bacterial lysis3. Release of nitric oxide that is deadly to several otherwise antibody-resistant bacteria4. Cytokine release of interleukins (IL1, IL2, IL4, and IL12)5. Angiogenesis via VEGF that promotes capillary budding6. Recruitment of other cells into the wound that continue the healing process7. Different homeostatic roles of macrophages and Langerhans cells, including wound repair, follicle regeneration, salt bal-ance, and cancer regression and progression in the skinInterestingly, the inflammatory phase determines the dif-ference between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors


Surgery_Schwartz

Surgery_Schwartz. between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors affect the inflammatory phase of wound healing directly. These include pressure, tissue hypoxia, infection, tissue contamination, desiccation, and maceration. Systemic factors include age, stress, and comorbid conditions such as diabetes, vascular insufficiency, immunocompromise, malnourishment, obesity, and smoking. The common thread, however, in all nonhealing chronic wounds is the persistence of proinflammatory conditions. These specific tissue deficits result in a chronic cycle of chronically migrating inflammatory cells (PMNs, macrophages) that scavenge early healing tissue, degrade the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of


Surgery_Schwartz

Surgery_Schwartz. the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of healing: cell proliferation, tissue remodeling, and resolution.Biofilm One of the recent discoveries in the area of biofilm is an important microbial factor that impedes healing by affecting inflammatory processes in the wound-healing continuum. Biofilm comprises a colony of microorganisms enveloped with a matrix of extracellular polymers also known as extracellular polymeric substance (EPS) (Fig. 45-10). EPS affects chronic and acute dermal wounds. Its life cycle and effects on the bacterial colonies it protects are shown in Figs. 45-11 and 45-12. These include antibiotic resistance; latency (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in


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Surgery_Schwartz. (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in which behavior is coordinated through a “chemical” vocabulary).Proliferation. This phase is arguably the first step towards restoration of tissue continuity. It is characterized by the pro-duction of extracellular matrix by the fibroblast, the most prominent cell type in the proliferative phase. Fibroblasts are Brunicardi_Ch45_p1967-p2026.indd 197201/03/19 6:26 PM 1973PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-10. Slough that also comprises biofilm.Figure 45-11. The lifecycle of biofilm.Figure 45-12. Biofilm is a barrier to wound healing.V. choleraebiofilmPhytoplanktonMetabolicallyactive cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe


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Surgery_Schwartz. cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe architects of wound healing and appear in the wound right at the end of the inflammatory phase. Collectively, fibroblasts support several major functions that lead to tissue repair, includ-ing the formation of collagen and the structural creation of the extracellular matrix. The formation of fibrin and fibronectin that is precipitated from the blood clot results in the formation of a provisional extracellular matrix that serves as a scaffold. Typically, this matrix can be compared to the framework of a building without any walls or windows. The protein scaf-fold serves as a solid framework that subsequently hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within


Surgery_Schwartz

Surgery_Schwartz. hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within the fibroblast matrix. Paradoxically, the major activat-ing factor responsible for the formation of capillary buds is low oxygen tension. Poor oxygenation of the tissues increases Brunicardi_Ch45_p1967-p2026.indd 197301/03/19 6:26 PM 1974SPECIFIC CONSIDERATIONSPART IIthe expression of hypoxia inducible factor (HIF) by endothe-lial cells. Specific DNA sequences of cells that regulate angio-genesis are turned on by HIF. This paradoxical negative loop is directly related to a low oxygen tension within the tissues. Subsequent release of the epidermal growth factor EGF and the transforming growth factor TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the


Surgery_Schwartz

Surgery_Schwartz. TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the edges of the wound on all sides migrate towards the center of the wound. This process is facilitated by several factors, including angiogenesis, neovas-cularization, and the release of fibroblast growth factor TGF-β and epidermal growth factor. The formation of the extracellular matrix is the key process that leads to subsequent reepithelial-ization. The extracellular matrix is primarily made of collagen. The different types of collagen that occur more predominantly in different types of tissues characterize the type of healing that occurs. Specifically, type I is present in scar tissues. After the formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger


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Surgery_Schwartz. formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger RNA, the collagen gets attached to hydroxylation of protein and lysine. The hydroxyproline in the collagen is responsible for the stable helical confirmation that is critical for the formation of a robust strong scar. It then transforms itself into a classical triple helical structure that is subsequently modified through glycosylation. It is important to realize that increased collagen stability is directly related to the degree of hydroxylation of the collagen and that fragile forms of colla-gen (which result in a fragile scar) are largely due to increases in nonhydroxylated collagen forms. Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile


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Surgery_Schwartz. Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile and can easily undergo denaturation and lysis.The next step is the cleavage of the procollagen N and C terminal peptides. A very important extracellular enzyme called lysyl oxidase is responsible for the strengthening of collagen by the formation of strong, stable cross-linkages. Microscopic examination of stable mature scars reveals that strong cross-linkages present in the intramolecular and the intermolecular compartments directly correlate with strength and stability. Epi-dermal cells migrate over the scaffold, and after the epithelial bridge is completed, enzymes are released to dissolve the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when


Surgery_Schwartz

Surgery_Schwartz. the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when the fibroblasts differentiate into myofibroblasts. Myofibroblasts are similar to smooth muscle cells, have the same amount of actin (responsible for mobility), and are responsible for contraction it peaks at around 10 days post injury but can continue for several weeks. Myofibroblasts attach to the extra cellular matrix (ECM) at the wound edges and to each other as well as to the wound edges via desmosomes and the fibronexus, through which actin in the myofibroblast is linked across the cell membrane to molecules in the extracellular matrix like fibro-nectin and collagen. This in turn facilitates the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked


Surgery_Schwartz

Surgery_Schwartz. the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked collagen scar with reepithelization heralds the end of the proliferative phase. Contraction usually does not occur symmetrically; instead, most wounds have an “axis of contraction” that allows for greater organization and alignment of cells with collagen.Remodeling/Maturation. The remodeling phase is also termed the maturation phase. It is primarily characterized by the remodeling of collagen through a balance between collagen for-mation and collagen lysis that results in the formation of a strong scar. Biochemically, the collagen is remodeled from type III to type I and is also accompanied by complete reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen


Surgery_Schwartz

Surgery_Schwartz. reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen molecule at different but specific locations on all three chains and break it down to characteristic three-quarter and one-quarter pieces. These collagen fragments undergo further denaturation and digestion by other proteases. There is significant remodeling of the collagen during this process. It is aligned along tension lines, and significant reabsorption of water from the collagen fibers result in a denser alignment and stronger cross-linking. The remodeling phase establishes a new equilibrium with the forma-tion of an organized scar. Several molecules, including TGF-β, which induces intracellular signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has


Surgery_Schwartz

Surgery_Schwartz. signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has been delineated. This process is also facilitated by apoptosis and programmatic cell death, which helps to former a thinner scar that is stronger and more cosmeti-cally appealing. This phase begins 3 weeks after the injury and continues for over 1 year. One must realize that despite the best cross-linking, scar tissue is weaker than injured skin and regains only 80% of its uninjured tensile strength. As it matures fur-ther, it becomes less red and less vascular because the reduced biologic activity within the scar renders the vascular capillaries redundant and they apoptose.RECONSTRUCTIVE SURGERYReconstructive surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma,


Surgery_Schwartz

Surgery_Schwartz. surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma, cancer, degeneration, congenital abnor-malities, and aging. The primary adverse consequence of lost or impaired tissue is functional disability, which includes physical, psychologic, or social dysfunction. The clinical objective is to reestablish normal anatomy, function, and appearance in order to restore the patient as closely as possible to normal health. The most useful techniques transfer and modify tissues in the form of tissue grafts and surgical flaps.RECONSTRUCTIVE STRATEGIES AND METHODSThe main aim of wound healing is to achieve a closed wound. Ordinarily, wounds heal via three main mechanisms:1. Primary intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary


Surgery_Schwartz

Surgery_Schwartz. intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary intention can only be imple-mented when the closure of the wound is precise and there is minimal disruption to the local tissue or the epithelial basement membrane. Typically, this wound seals off within 24 hours. Healing is faster than healing by secondary inten-tion, and there is the least amount of scarring.2Brunicardi_Ch45_p1967-p2026.indd 197401/03/19 6:26 PM 1975PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 452. Secondary intention: Tissue loss following major trauma results in the formation of granulation tissue, which results in a broader scar (see earlier section, “Phases of Wound Healing”).3. Tertiary intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing


Surgery_Schwartz

Surgery_Schwartz. intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing include healing through the use of tissue grafts, including skin grafts and substitutes.Skin Grafts and Skin SubstitutesSkin grafting methods date back millennia to ancient India, where they were used to resurface nasal defects. They were introduced in the modern era by Guiseppe Baronio, an Italian physician who studied skin grafting techniques in sheep and published his work entitled Degli Innesti Animali (On Grafting in Animals) in 1804.4It is important to know the basic anatomic structure of skin in order to understand the principles of skin grafting. Skin is comprised of the epidermis, the dermis, specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that


Surgery_Schwartz

Surgery_Schwartz. specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that affords pri-mary barrier function. It begins with a layer of cells called the basal layer. These are cuboidal-shaped cells that multiply and differentiate into flattened, keratinized squamous cells, which progressively migrate from the basal layers until they are finally released from the surface in a process known as desquamation. The junction between the dermis and the epidermis is composed of projections from the dermis into the epidermis, which are called dermal papillae. This feature secures the epidermis to the dermis by resisting sheer forces transmitted from the skin surface, helping to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue


Surgery_Schwartz

Surgery_Schwartz. to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue and traverse the dermis and epithe-lium to reach the body surface. The dermal thickness and con-centration of skin appendages vary widely from one location to another on the body. The blood supply to the skin occurs in a variety of patterns that form the basis for transferring tissue-containing skin, which will be discussed later in this chapter. Regardless of the pattern, there is a network of vessels just below the dermis called the subdermal plexus that supplies the skin immediately above and is important in thermoregulation. Finally, terminal vessels and capillaries fill the dermis and pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and


Surgery_Schwartz

Surgery_Schwartz. pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and composite tissue grafts. Each has its advantages and disadvantages, and select-ing the best technique for a given circumstance depends on the reconstructive requirements, the quality of the recipient wound bed, and the availability of donor site tissue.Split-Thickness Grafts. An STSG is the simplest method of tissue transfer. The name is derived from how these grafts are harvested by cutting through (i.e., splitting) the dermis at various levels. Thin STSGs are harvested through the superficial levels of the dermis. Thick grafts are harvested through deeper layers and include a larger amount of dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain


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Surgery_Schwartz. dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain fewer elements of the dermal extracellular matrix such as elastic fibers. Thick grafts undergo greater amounts of primary contraction. This is important to remember when harvesting the graft because it is necessary to obtain sufficient tissue in order to restore the defect. On the other hand, thin grafts allow the wound to undergo a greater amount of contraction in a process traditionally referred to secondary contraction of the graft. This becomes important if the wound is adjacent to a mobile structure such as the oral commissure, which might be distorted as healing progresses. Thin grafts also have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater


Surgery_Schwartz

Surgery_Schwartz. have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater metabolic needs.A variety of techniques have been described to maximize the surface area that can be covered by harvested skin amount while minimizing the size of the donor site.5 One approach is to process the harvested skin into micrografts using devices spe-cially designed for this purpose in the operating room. Another method is fractional skin harvesting, which involves harvesting a large number of full-thickness skin tissue columns that are then seeded onto the wound surface. The traditional method, however, is to mesh the graft. Meshed grafts usually also have enhanced reliability of engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary


Surgery_Schwartz

Surgery_Schwartz. engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary intention from the sur-rounding graft skin. The major drawbacks of meshed grafts are poor cosmetic appearance and high rates of secondary contrac-tion. Meshing ratios used usually range from 1:1.5 to 1:6, with higher ratios associated with magnified drawbacks related to meshing. For any case, a decision to mesh the graft must be balanced against the disadvantages. Other differences between thin and thick STSGs include final durability, pigmentation, and tendency to desiccation of the final result. The distinguishing characteristics of skin grafts types based on thickness are sum-marized in Fig. 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells.


Surgery_Schwartz

Surgery_Schwartz. 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells. These cells migrate across the wound surface and Figure 45-13A. Skin grafts categorized based on thickness.ThinIntermediateSplit skinThickFull thicknessskinABrunicardi_Ch45_p1967-p2026.indd 197501/03/19 6:26 PM 1976SPECIFIC CONSIDERATIONSPART IIDermal content1° contraction2° contractionEngraftmentDurabilityPigmentationResist desiccationRecipient bedAppearanceSTSG(thin) ++++++++++++++++++++++++++++++++++++++++++++++++++++++STSG(thick)FTSGBFigure 45-13B. Characteristics of skin grafts.reepithelialize it. During this process, the donor site must be kept moist and free of bacterial contamination. Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the


Surgery_Schwartz

Surgery_Schwartz. Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the new skin matures with epidermal and dermal thickening and reac-tivation of sebaceous and sweat glands. Part of managing the donor site includes minimizing pain. Some recommended treat-ments include (a) subcutaneous anesthetic injection of adren-aline-lidocaine; (b) ice application; (c) topical agents such as lidocaine and bupivacaine; and (d) hydrocolloidand polyure-thane-based wound dressings accompanied with fibrin sealant.6 Maintaining air-tight coverage using transparent adhesive film dressing can protect the donor site during reepithelialization and minimize pain.Full-Thickness Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained


Surgery_Schwartz

Surgery_Schwartz. Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained subcutaneous tissue from the deep surface of the dermis in order to maximize the poten-tial for engraftment. Full-thickness grafts are associated with the greatest amount of primary contraction, the least amount of secondary contraction, the highest durability, and ultimately the best cosmetic appearance. As a result, they are frequently used in reconstructing superficial wounds of the face and the hands. These grafts require clean, well-vascularized recipient beds free of bacterial colonization, previous irradiation, or fibrous wound tissue. They also work poorly in wounds associated with previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are


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Surgery_Schwartz. previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are typically types of extra-cellular matrices that are often acellular in nature and are either human-derived (allografts), animal-derived (xenografts), tissue engineered, or a combination of the three.7 These substitutes most often are employed to replace lost dermal and/or epider-mal skin layers resulting from burns, trauma, and other super-ficial injuries to the outer skin layers. While a complete review of all of these commercially available materials is beyond the scope of this chapter, the benefits and applications of these use-ful adjuncts is growing, and they been have shown to play an important role in current as well as future reconstructive, regen-erative, and restorative measures for tissue and skin replace-ment. Essentially, they act similarly to grafts as they rely on


Surgery_Schwartz

Surgery_Schwartz. play an important role in current as well as future reconstructive, regen-erative, and restorative measures for tissue and skin replace-ment. Essentially, they act similarly to grafts as they rely on revascularization and autologous cell repopulation of the con-struct in order to “take” and become part of the lost anatomic structure they are acting to restore.Graft Take. Skin graft healing, or “take,” occurs in three phases: imbibition, inosculation, and revascularization. Plas-matic imbibition takes place during the first 24 to 48 hours after placement of the graft onto the defect. During this time, the graft is held in place by a thin film of fibrin, and the cellular elements survive by diffusion of oxygen and substrate from plasma pres-ent in the open wound. After 48 hours, a fine vascular network forms from capillaries and small blood vessels in the wound bed and advances through the fibrin layer toward the graft. These new vascular buds encounter open, cut end vessels on the deep


Surgery_Schwartz

Surgery_Schwartz. network forms from capillaries and small blood vessels in the wound bed and advances through the fibrin layer toward the graft. These new vascular buds encounter open, cut end vessels on the deep surface of the dermis of the graft and line up, forming loose anastomoses that begin to allow blood flow and the transfer of some nutrients and oxygen. This phase is called inosculation and is the period during which the graft is most at risk for fail-ure. If the tenuous alignment of vessels between the wound bed and the graft are disrupted, then the final phase of healing will not occur. Events that can cause graft failure at this time include mechanical shear, formation of a seroma or hematoma, or bac-terial contamination. The final phase of engraftment is called revascularization. During this phase, firmer vascular anastomo-ses are formed as the vessels heal, and the graft becomes per-fused from the wound bed. Signs of perfusion, such as improved coloration and evidence of capillary


Surgery_Schwartz

Surgery_Schwartz. this phase, firmer vascular anastomo-ses are formed as the vessels heal, and the graft becomes per-fused from the wound bed. Signs of perfusion, such as improved coloration and evidence of capillary refill, confirm engraftment and graft take. In most circumstances, these phases are complete by 4 to 5 days after graft placement. The dressing used after placing the skin graft is a critical part of success. It must prevent desiccation and shear stress from disrupting the graft, especially during the critical period of inosculation. Tie-over bolster dress-ings are a traditional method. Topical negative pressure wound dressings have been demonstrated to increase quantity and qual-ity of split-thickness skin graft take compared to traditional bol-ster dressings. The benefits are particularly evident in wounds with irregular surface contours in areas that might be difficult to avoid motion.8After skin graft take, the graft remains subject to late fail-ure due to mechanical shear,


Surgery_Schwartz

Surgery_Schwartz. evident in wounds with irregular surface contours in areas that might be difficult to avoid motion.8After skin graft take, the graft remains subject to late fail-ure due to mechanical shear, desiccation, or bacterial infection. Depending on the location and clinical setting, the graft should continue to be protected using dressings, topical moisturizing creams, or antibacterial medications as indicated until stable healing obtains in up to 2 weeks.Composite Grafts. Composite grafts contain other types of tissue besides skin. Additional elements must have low met-abolic requirements in order to survive the time required for revascularization. Composite grafts might include subcutane-ous fat, cartilage, perichondrium, and small amounts of muscle. Indications for composite grafts are limited to small areas with specialized tissue requirements such as nasal reconstruction. For example, excision of a skin cancer involving the nasal lobule may create a composite defect that involves


Surgery_Schwartz

Surgery_Schwartz. limited to small areas with specialized tissue requirements such as nasal reconstruction. For example, excision of a skin cancer involving the nasal lobule may create a composite defect that involves internal nasal lin-ing, supporting nasal cartilage, and external skin. The ear is a good donor site for a composite graft of tissue with a good color match for the face and small amounts of tissue configured natu-rally to simulate the contours of the nose. For example, harvest of tissue from the root of the helix of the ear causes a relatively inconspicuous donor site. The donor site for composite tissue grafts must be repaired with primary closure.Surgical Flaps. A surgical flap is a unit of tissue harvested from a donor site and transferred to another location for Brunicardi_Ch45_p1967-p2026.indd 197601/03/19 6:26 PM 1977PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45reconstructive purposes. The term “flap” is derived from tech-niques of adjacent skin tissue transfers fashioned as


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Surgery_Schwartz. 197601/03/19 6:26 PM 1977PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45reconstructive purposes. The term “flap” is derived from tech-niques of adjacent skin tissue transfers fashioned as flaps of skin that were elevated and folded into the defect. The distinguishing feature of a surgical flap is having a blood supply independent of the injured area. A graft must go through the phases of heal-ing described previously as it derives a new blood supply from the wound bed. A flap is brought to the wound with its own blood supply. This allows restoring tissue in areas of poor blood supply or with tissue requirements greater than what can be sup-ported through a period of diffusion only.There are a tremendous variety of surgical flaps that can be created depending on the individual patient’s reconstructive needs and available tissues. The challenge of reconstructive sur-gery is to design an appropriate flap to restore the defect with a minimal amount of morbidity related to the flap donor


Surgery_Schwartz

Surgery_Schwartz. needs and available tissues. The challenge of reconstructive sur-gery is to design an appropriate flap to restore the defect with a minimal amount of morbidity related to the flap donor site. The different kinds of flaps can be broadly classified by three distinct characteristics: (a) the types of tissue contained, (b) the proximity to the defect, and (c) the pattern of blood supply.The first way to classify different types of surgical flaps is by what tissue they contain. Nearly any type of vascularized tissue can be transferred as a surgical flap. One of the most com-mon is a cutaneous flap, which contains skin and subcutaneous tissue. Another versatile type is a muscle flap, which contains only muscle. Musculocutaneous flaps contain a portion of mus-cle along with the overlying skin and all the intervening tissues. An osseous flap contains a segment of bone, and an osteocuta-neous flap includes skin as well as the bone. Flaps can also be designed to include fascia and peripheral


Surgery_Schwartz

Surgery_Schwartz. and all the intervening tissues. An osseous flap contains a segment of bone, and an osteocuta-neous flap includes skin as well as the bone. Flaps can also be designed to include fascia and peripheral nerves. Visceral flaps contain segments of jejunum, stomach, colon, or the greater omentum. The choice of flap depends upon the reconstructive needs and availability of tissue.The second way to classify surgical flaps is by their prox-imity to the defect. The location and distance between the flap donor site and the defect usually dictate the method required to transfer the tissue with preservation of the blood supply. Local flaps have a donor site located immediately adjacent to the defect.9 Regional flaps are harvested from the same anatomic region as the defect. Distant flaps are harvested and trans-ferred from outside the anatomic region of the defect. Dur-ing the transfer of all of these flaps, the blood supply remains attached to the source anatomic region. The tissue transmitting


Surgery_Schwartz

Surgery_Schwartz. and trans-ferred from outside the anatomic region of the defect. Dur-ing the transfer of all of these flaps, the blood supply remains attached to the source anatomic region. The tissue transmitting the blood supply is called the flap pedicle. When the blood supply is not divided during the transfer, it is referred to as a pedicled flap. If the distance between the donor site and the defect exceeds the length of the pedicle, the vessels can Figure 45-14. Limberg flap.be divided and then reattached to uninjured vessels within or adjacent to the defect after the tissue is placed there. This technique is called a free tissue transfer, and flaps transferred in this fashion are called free flaps because for some period of time during the procedure the tissue of the flap is completely separated, or free, of the patient. The diameter of the blood vessels that supply common surgical flaps is usually less than 5 mm. Repairing blood vessels of this caliber is considered microvascular surgery,


Surgery_Schwartz

Surgery_Schwartz. or free, of the patient. The diameter of the blood vessels that supply common surgical flaps is usually less than 5 mm. Repairing blood vessels of this caliber is considered microvascular surgery, and techniques for doing this are part of reconstructive microsurgery.The third and perhaps most important way to classify dif-ferent surgical flaps is by the pattern of their blood supply.10 Using this criterion, flaps are traditionally divided into random pattern flaps, axial pattern flaps, musculocutaneous flaps, fas-ciocutaneous flaps, direct cutaneous flaps, perforator flaps, and free flaps. These designations are based on how vessels reach from the deeper, usually named, arteries and veins to the super-ficial tissues and skin. These are described in greater detail in the following section.Random Pattern Flaps. The simplest flap designs are random pattern flaps, so named because the blood supply is based on unnamed vessels in the attached base of the flap that perfuse through the


Surgery_Schwartz

Surgery_Schwartz. Pattern Flaps. The simplest flap designs are random pattern flaps, so named because the blood supply is based on unnamed vessels in the attached base of the flap that perfuse through the subdermal plexus.11 Random flaps are typically used to reconstruct relatively small, full-thickness defects, and they are designed following geometric principles of skin rearrange-ment with a traditional length-to-width ratio of 3:1. Exceptions to this principle regarding reliable dimensions abound, however, because of the variability in the patterns of perfusion and the density of the subdermal plexus in different regions of the body.Random pattern flaps can be further subdivided based on the geometry of the transfer. Examples of this are transposition flaps, advancement flaps, and interpolated flaps. A transposition flap is fashioned adjacent to an area needing reconstruction and rotated into the defect. Large transposition flaps can require a skin graft to close the donor site. To avoid this


Surgery_Schwartz

Surgery_Schwartz. A transposition flap is fashioned adjacent to an area needing reconstruction and rotated into the defect. Large transposition flaps can require a skin graft to close the donor site. To avoid this problem, spe-cialized types of transposition flaps have been devised. One that is particularly useful is called a Z-plasty. In this technique, two flaps are rotated, each into the donor site of the other, to rearrange the tissues in a way that redirects the lines of tension and lengthens the central limb. Another is the rhomboid (Lim-berg) flap (Fig. 45-14). In this technique, a skin flap is precisely designed with opposing 60° and 120° angles at the corners of a rhomboid designed immediately adjacent to the defect. This design can be modified to allow the flap to rotate into the defect Area withmaximum laxityABCD120°60°Brunicardi_Ch45_p1967-p2026.indd 197701/03/19 6:26 PM 1978SPECIFIC CONSIDERATIONSPART IIwith primary closure of the donor site with minimal distortion of the surrounding


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Surgery_Schwartz. laxityABCD120°60°Brunicardi_Ch45_p1967-p2026.indd 197701/03/19 6:26 PM 1978SPECIFIC CONSIDERATIONSPART IIwith primary closure of the donor site with minimal distortion of the surrounding tissues as shown in the case of a gluteal repair (Fig. 45-15A–B, by complex closure; Fig. 45-15C–E, by modi-fied Limberg flap). Modifications on the angle, including the Dufourmental modification, cause the parametric configuration to be optimized based on the defect12 (Fig. 45-16). Rotational flaps are a type of transposition that is semicircular in design, allowing the tissue to be rotated and permitting primary closure. Advancement flaps differ from transposition flaps because the tissue is moved forward from the donor site along the flap’s long axis rather than being rotated about a point. Two common vari-ants include the rectangular advancement flap (Fig. 45-17) and the V-Y advancement flap (Fig. 45-18). Finally, interpolation flaps rotate about a pivot point but are used to transfer tissue


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Surgery_Schwartz. vari-ants include the rectangular advancement flap (Fig. 45-17) and the V-Y advancement flap (Fig. 45-18). Finally, interpolation flaps rotate about a pivot point but are used to transfer tissue ABCDEFigure 45-15. Reconstruction of a gluteal defect using complex closure and reconstruction of a gluteal defect using a modified Limberg flap.Brunicardi_Ch45_p1967-p2026.indd 197801/03/19 6:26 PM 1979PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-16. Dufourmental modification.Figure 45-17. Rectangular advancement flap.Figure 45-18. V-Y flap closure.BABYXZCADEF˜1˜2°Advancement flapABCDinto a nonadjacent area with an intervening portion of undam-aged tissue between the donor site and the defect (Fig. 45-19).Axial Pattern Flaps. Historically, surgeons made an increas-ing variety of surgical flaps to address a greater assortment of reconstructive problems. In the process, they noticed that some of these flaps routinely violated the strict limitations of accepted length-to-width


Surgery_Schwartz

Surgery_Schwartz. surgical flaps to address a greater assortment of reconstructive problems. In the process, they noticed that some of these flaps routinely violated the strict limitations of accepted length-to-width ratio. Further investigation demon-strated that these flaps had significant arteries running parallel to the long axis of the flap. These flaps became known as axial pattern flaps.12 The earliest example of this type of flap is the deltopectoral flap, originally described in 1971 by Bakamjian (Fig. 45-20A,B). This flap is based on cutaneous vessels perfo-rating from inside the chest from the internal mammary artery and vein. After entering the subcutaneous tissues, they travel obliquely from the sternal border toward the deltoid area of the arm. Long flaps can be designed based on these vessels, which can reach into the head and neck to provide thin tissue from the upper chest to restore defects, especially after tumor ablation. Other important and useful axial pattern flaps are the groin


Surgery_Schwartz

Surgery_Schwartz. which can reach into the head and neck to provide thin tissue from the upper chest to restore defects, especially after tumor ablation. Other important and useful axial pattern flaps are the groin flap and the posterior thigh flap.Musculocutaneous Flaps. The vascular pattern of musculo-cutaneous flaps arises from major vessels that primarily supply a muscle and then secondarily supply the skin through multiple small vessels traversing between the superficial surface of the muscle and the subdermal plexus. The discovery of this pat-tern of cutaneous blood supply was a major breakthrough in reconstructive surgery because it made it possible to transfer units of tissue much larger than was possible with random or axial pattern flaps, enabling plastic surgeons to restore a greater range of deformities. Mathes and Nahai classified individual muscles into five types (I–V) according to the number and dom-inance of the vascular pedicles supplying each13 (Table 45-1). There may be advantages


Surgery_Schwartz

Surgery_Schwartz. Mathes and Nahai classified individual muscles into five types (I–V) according to the number and dom-inance of the vascular pedicles supplying each13 (Table 45-1). There may be advantages to including muscle in a surgical flap besides ensuring adequate blood supply to the overlying skin. The classic example is breast reconstruction using a latissimus dorsi myocutaneous flap (Fig. 45-21A–C). Here, the latissimus muscle is harvested pedicled on the thoracodorsal vessels and transposed anteriorly onto the chest wall. Muscle is a highly vascularized tissue that is bulky and deformable. It can help to repair visible surface contour deformities by increasing the pro-jection of tissue in the defect to reach the level of the surround-ing undamaged tissues. It can also easily contour to fill spaces in a complicated wound surface, thus helping to prevent small fluid collections in recesses, which can be a harbor bacteria and become a nidus of infection. It is also possible to provide


Surgery_Schwartz

Surgery_Schwartz. fill spaces in a complicated wound surface, thus helping to prevent small fluid collections in recesses, which can be a harbor bacteria and become a nidus of infection. It is also possible to provide func-tional restoration using musculocutaneous flaps by coapting the motor nerve of the muscle in the flap to a corresponding motor nerve in the defect. This method can be used to restore motor function in patients with motor loss in the extremities or face.Fasciocutaneous Flaps. Rather than having a blood supply primarily from underlying muscle, the skin and subcutaneous tissues of some anatomic regions are supplied from vessels communicating with the underlying superficial or deep fascia. Such flaps are referred to as fasciocutaneous flaps. The artery and vein of the flap pedicle passes between rather than through muscles, form a plexus of vessels within the fascia, and then send multiple small vessels to the subdermal plexus to perfuse the skin. There are clinical circumstances when a


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Surgery_Schwartz. rather than through muscles, form a plexus of vessels within the fascia, and then send multiple small vessels to the subdermal plexus to perfuse the skin. There are clinical circumstances when a fasciocutane-ous flap might have advantages over a musculocutaneous flap. Fasciocutaneous flaps are usually thinner compared to muscu-locutaneous flaps. They also do not create a functional loss of muscle in the donor site. Mathes and Nahai classified fasciocu-taneous flaps into types A, B, and C (Table 45-2) based on how the vascular pedicle reaches the fascia from the major vessels deep to the fascia and muscles. Sural perforator fasciocutaneous flaps (Fig. 45-22A–D) are a modern example of reconstructing lower extremity defects that would be difficult to reconstruct without microvascular surgery.Direct Cutaneous Flaps. Some surgical flaps have a vascu-lar pedicle that reaches directly to the superficial tissues and subdermal plexus without passing through a muscle or fascia plexus. These


Surgery_Schwartz

Surgery_Schwartz. Cutaneous Flaps. Some surgical flaps have a vascu-lar pedicle that reaches directly to the superficial tissues and subdermal plexus without passing through a muscle or fascia plexus. These are called direct cutaneous flaps.Perforator Flaps. The final kind of surgical flap classified by the pattern of blood supply is the perforator propeller flap.14,15 The geometric measurements that are critical to its success are summarized in Fig. 45-23. Reconstructive procedures based Brunicardi_Ch45_p1967-p2026.indd 197901/03/19 6:27 PM 1980SPECIFIC CONSIDERATIONSPART IIFigure 45-19. Forehead flap for nasal reconstruction.ADBECFon these flaps are the result of complementary advances in our understanding of cutaneous blood supply and improved surgical techniques.Ian Taylor and a team of investigators from Melbourne, Australia, discovered that the blood supply to all portions of the skin was organized into discreet units, which they called angiosomes18. Analogous to dermatomes that describe the


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Surgery_Schwartz. from Melbourne, Australia, discovered that the blood supply to all portions of the skin was organized into discreet units, which they called angiosomes18. Analogous to dermatomes that describe the patterns of cutaneous sensation supplied by single sensory nerves, the cutaneous perfusion is organized into angiosomes supplied by a single arteries. These arteries arise from source blood vessels located deep to other structures like muscle and fascia and penetrate through as perforating vessels. Often the artery is accompanied by two venae commitantes, but in many regions an additional venous drainage system is present in the superficial planes. The territories of adjacent angiosomes over-lap similarly to how dermatomes overlap. An angiosome is defined by the limits of an artery’s terminal branching. At the borders, these arterioles form anastomoses with the neighbor-ing angiosome. The vessels that pass between these anatomic angiosomes are called choke vessels. In life, these may open or


Surgery_Schwartz

Surgery_Schwartz. At the borders, these arterioles form anastomoses with the neighbor-ing angiosome. The vessels that pass between these anatomic angiosomes are called choke vessels. In life, these may open or close in response to physiologic changes in order to increase or decrease, respectively, an artery’s dynamic angiosome momen-tarily. Accordingly, at any given time point, the dynamic angio-some of an artery may be approximated by the volume of tissue stained by an intravascular administration of fluorescein into that artery (indicating the reach of blood flow from that artery into tissues). The potential angiosome of an artery is the vol-ume of tissue that can be included in a flap that has undergone conditioning (see the following section). Both the dynamic and potential angiosomes extend beyond the anatomic angiosome of an artery. Although the angiosome concept provides some guidance to the size and volume limits of a flap harvest, there remains no quantifiable method to predict safe flap


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Surgery_Schwartz. the anatomic angiosome of an artery. Although the angiosome concept provides some guidance to the size and volume limits of a flap harvest, there remains no quantifiable method to predict safe flap harvest lim-its with precision.Brunicardi_Ch45_p1967-p2026.indd 198001/03/19 6:27 PM 1981PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-20A, B. Deltopectoral flap for cheek reconstruction.Table 45-1Mathes-Nahai classification of muscular flapsCLASSIFICATIONVASCULAR SUPPLYEXAMPLEType IOne vascular pedicleGastrocnemiusType IIDominant and minor pedicles (the flap cannot survive based only on the minor pedicles)GracilisType IIITwo dominant pediclesRectus abdominisType IVSegmental pediclesSartoriusType VOne dominant pedicle with secondary segmental pedicles (the flap can survive based only on the secondary pedicles)Pectoralis majorALimit of areatubed ondeep aspectSkinGraftsBTissue Expansion. Tissue expansion is a technique that increases the amount of tissue in a surgical flap by


Surgery_Schwartz

Surgery_Schwartz. only on the secondary pedicles)Pectoralis majorALimit of areatubed ondeep aspectSkinGraftsBTissue Expansion. Tissue expansion is a technique that increases the amount of tissue in a surgical flap by first plac-ing an inflatable device into the tissue beneath the planned flap and gradually expanding the tissue by regular inflation. Staged reconstruction using tissue expansion can significantly increase the amount of local, well-matched tissue for transfer while decreasing donor site morbidity. The most common method of skin expansion involves the placement of an inflatable silicon elastomer similar to a balloon with a filling port that is gener-ally positioned in an easily accessible location beneath the skin. After wound healing, the device is gradually inflated by serial injections of sterile saline solution into the filling port. The process can require several weeks, depending on the amount of expansion and compliance of the tissues. When expansion is complete, the expander is


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Surgery_Schwartz. sterile saline solution into the filling port. The process can require several weeks, depending on the amount of expansion and compliance of the tissues. When expansion is complete, the expander is removed, and the resulting expanded tissue is transferred into the defect.The process of expanding flaps confers physiologic bene-fits that increase the reliability of the flap tissue. Histologically, expanded skin demonstrates thickened dermis with enhanced vasculature and diminished subcutaneous fat. Studies have shown that the increased amount of skin is the result of actual generation of new tissue. Also, the blood supply to an expanded flap is improved because of the period of delay associated with expansion process and the capsule formed around the device is highly vascular and contributes to the quality of blood supply.16The disadvantages of tissue expansion have to do with pos-sible complications, which include infection, hematoma, seroma, expander extrusion, implant failure, skin


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Surgery_Schwartz. to the quality of blood supply.16The disadvantages of tissue expansion have to do with pos-sible complications, which include infection, hematoma, seroma, expander extrusion, implant failure, skin necrosis, pain, and peripheral nerve injury. Furthermore, an inflated expander is vis-ible, and the temporary deformity may cause patients distress.Tissue expansion has found particular usefulness in man-aging giant congenital nevi, secondary reconstruction of exten-sive burn scars, scalp reconstruction, and breast reconstruction. Expanders are available in a multitude of shapes and sizes, depending on the reconstructive needs. The technique permits reconstruction with tissue of similar color, texture, and thick-ness, with minimal donor site morbidity.PEDIATRIC PLASTIC SURGERYCongenital Craniofacial AnomaliesIn 1981, Whitaker et al introduced a simple classification sys-tem to help conceptualize the vast array of congenital pathology involving the craniofacial region.17 Based on anatomy,


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Surgery_Schwartz. AnomaliesIn 1981, Whitaker et al introduced a simple classification sys-tem to help conceptualize the vast array of congenital pathology involving the craniofacial region.17 Based on anatomy, etiology, and current treatment principles, most cra-niofacial anomalies can be classified into one of four categories: clefts, synostoses, atrophy-hypoplasia, or hypertrophy-hyper-plasia-neoplasia (Table 45-3).Clefts. Arguably, no operation in plastic surgery is more demanding of reconstructive principle and aesthetic intuition 3Brunicardi_Ch45_p1967-p2026.indd 198101/03/19 6:27 PM 1982SPECIFIC CONSIDERATIONSPART IIFigure 45-21. Breast reconstruction (right side) with a latissimus flap.B Preop, right mastectomy and left previous implant reconstructionC Postoperative: bilateral latissimus flap with implantSkin usedfor flapLatissimusdorsimuscleClosedincisionImplantundermusclesLatissimusdorsi flapin placeATable 45-2Nahai-Mathes classification of fasciocutaneous flapsCLASSIFICATIONVASCULAR


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Surgery_Schwartz. with implantSkin usedfor flapLatissimusdorsimuscleClosedincisionImplantundermusclesLatissimusdorsi flapin placeATable 45-2Nahai-Mathes classification of fasciocutaneous flapsCLASSIFICATIONVASCULAR SUPPLYEXAMPLEType ADirect cutaneous vessel that penetrates the fasciaTemporoparietal fascial flapType BSeptocutaneous vessel that penetrates the fasciaRadial artery forearm flapType CMusculocutaneous vessel that penetrates the fasciaTransverse rectus abdominis myocutaneous flapthan a cleft lip repair. Orofacial clefting is the most common birth defect in the world. Cleft lip, with or without cleft palate (CL/P), occurs spontaneously among Caucasian populations in approximately 1 out of every 1000 births. It is over twice as common (1 in 450) among Asians and Native Americans and half as common (1 in 2000) in African Americans. There is a predilection among males, who are twice as likely to be affected as females. Left-sided cleft lip is twice as common as right and nine times as common as


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Surgery_Schwartz. (1 in 2000) in African Americans. There is a predilection among males, who are twice as likely to be affected as females. Left-sided cleft lip is twice as common as right and nine times as common as bilateral. Of patients born with CL/P, 29% have associated anomalies, which can range from minor physical differences to major organ involvement. While a fam-ily history of CL/P remains the strongest known predictive factor, other extrinsic risk factors include maternal smoking or early exposure to the anticonvulsant drug phenytoin.18Epidemiologically, isolated cleft palate (CP) appears to be distinctly different from CL/P. CP occurs in 1 of every 2000 live births. It is twice as common in females, and it demonstrates no racial or ethnic preponderance. Nearly half of patients with iso-lated CP have a diagnosable syndrome and additional congeni-tal anomalies. Evaluation by a geneticist is therefore indicated in all babies born with isolated CP. Like CL/P, isolated CP is multifactorial.


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Surgery_Schwartz. CP have a diagnosable syndrome and additional congeni-tal anomalies. Evaluation by a geneticist is therefore indicated in all babies born with isolated CP. Like CL/P, isolated CP is multifactorial. Known environmental risk factors include mater-nal smoking or alcohol consumption, folate deficiency, use of steroids or anticonvulsant medications, or retinoid (vitamin A) excess.Some familial patterns of orofacial clefting have been linked to specific genetic mutations. Van der Woude syndrome, an autosomal dominant form of CL/P associated with lower lip pits, is caused by an IRF6 gene mutation (Fig. 45-24).23 Stick-ler syndrome should be suspected in patients with isolated CP, Brunicardi_Ch45_p1967-p2026.indd 198201/03/19 6:27 PM 1983PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-22. Reconstruction of a lateral malleolar defect using a reverse sural perforator flap.Figure 45-23. Geometric considerations for a propeller flap.ABCDABaDefectPerforatorbc+CDwith associated eye


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Surgery_Schwartz. 45-22. Reconstruction of a lateral malleolar defect using a reverse sural perforator flap.Figure 45-23. Geometric considerations for a propeller flap.ABCDABaDefectPerforatorbc+CDwith associated eye defects, sensorineural hearing loss, and joint abnormalities. This constellation of findings is due to an autosomal dominant mutation in a procollagen gene. Stickler is also the most common syndrome associated with Pierre Robin sequence (micrognathia, glossoptosis, and respiratory distress).19 These examples help emphasize the importance of early genetic workup for patients in whom a syndrome is suspected.Embryology of the Lip and Palate The “primary palate,” which includes the nostril sill, upper lip, alveolus, and hard pal-ate anterior to the incisive foramen, forms from fusion between the medial nasal and maxillary prominences during weeks 4 through 7 of gestation.20,24 Development of the hard palate pos-terior to the incisive foramen and the soft palate, which are col-lectively known as


Surgery_Schwartz

Surgery_Schwartz. nasal and maxillary prominences during weeks 4 through 7 of gestation.20,24 Development of the hard palate pos-terior to the incisive foramen and the soft palate, which are col-lectively known as the “secondary palate,” occurs during weeks Brunicardi_Ch45_p1967-p2026.indd 198301/03/19 6:27 PM 1984SPECIFIC CONSIDERATIONSPART IIFigure 45-24. Van der Woude syndrome.Table 45-3Classification of craniofacial anomalies211. Clefts2. Synostoses3. Atrophy–hypoplasia4. Hypertrophy–hyperplasia–neoplasia6 through 12 of gestation. The lateral palatine processes initially hang vertically on either side of the developing tongue. Around week 8, these palatal shelves rotate into a horizontal orientation, bringing their free edges into close proximity with the nasal septum. Midline fusion then commences, proceeding posteriorly from the incisive foramen (Fig. 45-25).23Normal and Cleft Anatomy There are several key defining characteristics of the lip that make its surgical repair so chal-lenging. On


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Surgery_Schwartz. proceeding posteriorly from the incisive foramen (Fig. 45-25).23Normal and Cleft Anatomy There are several key defining characteristics of the lip that make its surgical repair so chal-lenging. On the surface, the philtrum of the upper lip is com-prised of paired philtral columns and a central philtral dimple. The white roll passes along the vermilion-cutaneous junction, peaking at the base of the philtral columns and dipping centrally to form Cupid’s bow. Deep to the surface, the paired orbicularis oris muscles originate lateral to the oral commissures and encir-cle the mouth, decussating in the midline and sending off dermal insertions to the philtrum. This intrinsic muscle of the lip pro-vides oral competence and assists with speech production and facial expression. Continuity of the orbicularis oris muscle is disrupted in babies born with a cleft lip. Aberrant muscle inser-tion into the piriform aperture laterally and the anterior nasal spine medially contributes to the hallmark


Surgery_Schwartz

Surgery_Schwartz. orbicularis oris muscle is disrupted in babies born with a cleft lip. Aberrant muscle inser-tion into the piriform aperture laterally and the anterior nasal spine medially contributes to the hallmark appearance of cleft lip and nasal deformity (Fig. 45-26).20,25Clefts of the lip can be described as unilateral or bilateral and microform, incomplete, or complete. Microform cleft lip is the most minor variant and may manifest as subtly as a small notch in the vermilion. An incomplete cleft lip, by definition, requires an intact nasal sill. The term can otherwise be applied to a wide spectrum of anomaly, ranging from a partial cleft of the lip alone (Fig. 45-27A) to a near-complete cleft of the entire primary palate. A complete cleft lip involves all structures of the primary palate in their entirety, extending through the nasal sill and opening into the anterior nasal floor (Fig. 45-27B).20,26The normal palate functions primarily as a speech organ, but it is also intimately involved in


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Surgery_Schwartz. entirety, extending through the nasal sill and opening into the anterior nasal floor (Fig. 45-27B).20,26The normal palate functions primarily as a speech organ, but it is also intimately involved in feeding, swallowing, and breathing. The soft palate, or velum, together with lateral and posterior pharyngeal walls, can be conceptualized as a valve that regulates the passage of air through the nasopharynx. The paired levator veli palatini muscles descend from the cranial base and decussate in the midline to form a sling within the soft palate. This sling acts to elevate the velum against the posterior pharyngeal wall, effectively closing the velopharyngeal port. In patients with cleft palate, the levator muscles are unable to cross the midline. Instead, they run parallel to the cleft margin and insert aberrantly into the posterior edge of the hard palate (Fig. 45-28A,B). Air is allowed to leak through the nose dur-ing attempts to suck or speak. This inability to build negative or


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Surgery_Schwartz. margin and insert aberrantly into the posterior edge of the hard palate (Fig. 45-28A,B). Air is allowed to leak through the nose dur-ing attempts to suck or speak. This inability to build negative or positive intraoral pressure makes either task difficult, if not impossible. The tensor veli palatini muscles, which normally function to vent and drain the Eustachian tubes, are also dis-rupted in cleft anatomy. Eustachian tube dysfunction predis-poses patients to frequent bouts of otitis media, which can lead to permanent hearing loss if left untreated.20The most clinically useful system to describe cleft pal-ate morphology is the Veau classification. A Veau I cleft is midline and limited to the soft palate alone, whereas a Veau II cleft may extend further anteriorly to involve the midline of the posterior hard palate (the “secondary palate”). A Veau III cleft is a complete unilateral cleft of primary and secondary pal-ates, in which the cleft extends through the lip, the alveolus, the


Surgery_Schwartz

Surgery_Schwartz. of the posterior hard palate (the “secondary palate”). A Veau III cleft is a complete unilateral cleft of primary and secondary pal-ates, in which the cleft extends through the lip, the alveolus, the entire length of the nasal floor on the cleft side, and the midline of the soft palate. Veau IV clefts are bilateral complete clefts of the primary palate that converge at the incisive foramen and continue posteriorly through the entire secondary palate (Fig. 45-29A,B). Not included in the Veau classification is the submucous cleft palate, which occurs when there is clefting of the soft palate musculature beneath intact mucosa. Submucous cleft palate classically presents as the triad of a bifid uvula, a midline translucency called the “zona Pellucida” and a palpable notch of the posterior hard palate.21Presurgical Infant Orthopedics Current literature suggests aesthetic outcomes in patients with complete unilateral or bilateral clefts may be improved by reestablishing more nor-mal


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Surgery_Schwartz. hard palate.21Presurgical Infant Orthopedics Current literature suggests aesthetic outcomes in patients with complete unilateral or bilateral clefts may be improved by reestablishing more nor-mal skeletal, cartilaginous, and soft tissue relationships prior to definitive lip repair. Presurgical infant orthopedics (PSIO) can help to narrow wide clefts and align dental arches in prepara-tion for surgery. Some methods of PSIO, such as nasoalveolar molding (NAM), provide the added benefits of elongating the columella and improving nasal tip asymmetry.22 The most com-mon barrier to PSIO implementation is its imposition on fami-lies, who must be willing and able to keep frequent follow-up appointments for appliance adjustment. An excellent alternative to PSIO is a lip adhesion procedure, in which a complete cleft is surgically converted to an incomplete cleft. This preliminary stage of lip repair restores soft tissue continuity at the nasal sill, which helps to realign the underlying dental


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Surgery_Schwartz. a complete cleft is surgically converted to an incomplete cleft. This preliminary stage of lip repair restores soft tissue continuity at the nasal sill, which helps to realign the underlying dental arches and reap-proximate the soft tissues. In addition, the nasal deformity can be improved, both by repositioning of the cleft side alar base and placement of nasal conformers.23Cleft Lip Repair Although cleft lip surgery can be traced to antiq-uity, it was not until the first half of the 20th century that sur-geons began to realize the inadequacy of a straight-line repair. In 1955, Ralph Millard pioneered his “rotation-advancement” tech-nique, which was the first to address upper lip length deficiency while preserving intricate philtral anatomy (Fig. 45-29C).24 The back-cut is designed high on the medial lip element just beneath the columella, enabling a downward rotation and leveling of Cupid’s bow, while the lateral lip element is advanced into the Brunicardi_Ch45_p1967-p2026.indd


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Surgery_Schwartz. on the medial lip element just beneath the columella, enabling a downward rotation and leveling of Cupid’s bow, while the lateral lip element is advanced into the Brunicardi_Ch45_p1967-p2026.indd 198401/03/19 6:27 PM 1985PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-25. Facial prominences and their contributions to facial development. Cleft lip results from failure of fusion between maxillary and medial nasal (a component of frontonasal) prominences.ACDEBrotation defect. Although other techniques exist, most lip repairs performed today are minor modifications of Millard’s original rotation-advancement principle.20Bilateral cleft lip presents an even greater set of challenges to the reconstructive surgeon. With no overlying orbicularis oris muscle, an unrestrained premaxilla rotates anteriorly, com-pletely displacing the incisor-bearing portion of the alveolus from the maxillary dental arch. Orbicularis continuity must be restored over an often protuberant premaxilla. The