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Surgery_Schwartz. Ideally, local tissues are used; however, when they are unavailable or inadequate, the amputated part can be a use-ful source of skin grafts or tissues for microvascular free transfers to the stump, which preserves length and avoids a more proximal amputation. Transected nerves from ampu-tation procedures can be managed using a technique called targeted muscle reinnervation (TMR). TMR surgery takes the transected peripheral nerves resulting from the amputation procedure, and a nerve transfer is then performed to freshly deinnervated motor nerves within the residual limb or stump. By performing these nerve transfers, the sensory and mixed-motor sensory nerves typically transected during amputation are given fresh motor nerves to rapidly reinnervate, which can directly aid in bioprosthetic function and improve pain control. The improvement in pain is a result of reducing phantom limb pain and symptomatic neuroma formation. This technique has shown to be a major advance over traditional


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Surgery_Schwartz. function and improve pain control. The improvement in pain is a result of reducing phantom limb pain and symptomatic neuroma formation. This technique has shown to be a major advance over traditional traction neurec-tomy techniques, which often contribute to increased phan-tom and residual limb pain rates and a much higher chance of symptomatic neuroma formation compared to TMR.54Oncologic Reconstructive SurgeryOncology-related reconstructive surgery has broad applica-tions in specialty of plastic and reconstructive surgery. Solid tumors necessarily destroy normal tissues, and surgical treat-ment involves excising the tumor with a margin of uninvolved normal tissue, which adds to the extent of tissue loss. As is illustrated in the case of a lower extremity sarcoma, recon-structive strategies are meticulously designed as an algorithm for effective functional and cosmetic restoration (Fig. 45-59) . Chemotherapy and radiation have side effects and com-plications that can cause tissue


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Surgery_Schwartz. are meticulously designed as an algorithm for effective functional and cosmetic restoration (Fig. 45-59) . Chemotherapy and radiation have side effects and com-plications that can cause tissue loss, leading to functional and cosmetic deformities that can be improved with recon-structive surgery. The goal of comprehensive cancer treatment is to restore the patient to full health, which includes normal function and appearance.8Figure 45-59. Algorithm for effective functional and cosmetic restoration after resection of a lower extremity sarcoma.Brunicardi_Ch45_p1967-p2026.indd 200801/03/19 6:31 PM 2009PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Reconstructive surgery in the context of oncology has sev-eral distinctive aspects compared to the larger field of recon-structive surgery in general. The procedure must be highly reliable in order to avoid surgical complications that might interfere with adjuvant therapies.Breast ReconstructionBreast cancer is the most common malignancy


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Surgery_Schwartz. general. The procedure must be highly reliable in order to avoid surgical complications that might interfere with adjuvant therapies.Breast ReconstructionBreast cancer is the most common malignancy besides skin can-cer in women and the second leading cause of cancer-related death for women in the United States. Breast reconstruction is an important part of comprehensive cancer treatment. A number of studies have shown that breast reconstruction, both imme-diate and delayed, does not impede standard oncologic treat-ment, does not delay detection of recurrent cancer, and does not change the overall mortality associated with the disease.46-48Preoperative counseling of the breast cancer patient regarding reconstruction options should include discussion of the timing and technique of reconstruction. It is important to ensure that the patient has realistic expectations of outcome and an understanding of the number of procedures that might be necessary to perform in order to obtain the best


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Surgery_Schwartz. It is important to ensure that the patient has realistic expectations of outcome and an understanding of the number of procedures that might be necessary to perform in order to obtain the best outcome. The plastic surgeon and surgical oncologist must maintain close communication to achieve optimal results.Delayed breast reconstruction occurs any time after the mastectomy is performed, usually 3 to 6 months after the opera-tion, depending on the patient’s circumstances and reasons for not electing immediate reconstruction. Although good out-comes can be obtained, it is more difficult to achieve a result that is similar to the preoperative breast shape and size because of established scarring of the chest wall. Nevertheless, it is a good option for patients who are undecided or not candidates for immediate reconstruction because of advanced disease or comorbidities.Immediate reconstruction is defined as initiation of the breast reconstructive process at the time of the ablative


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Surgery_Schwartz. candidates for immediate reconstruction because of advanced disease or comorbidities.Immediate reconstruction is defined as initiation of the breast reconstructive process at the time of the ablative sur-gery. Patients are considered candidates for immediate recon-struction who are in general good health and have stage I or stage II disease determined primarily by the size and location of the tumor. There are selected exceptions, such as when an extensive resection requires chest wall coverage. Breast recon-struction might be performed in these cases, but it is really incidental to achieving chest wall coverage. Disadvantages of immediate reconstruction include the potential delay of adju-vant therapy in the event of postoperative complications. Also, if there is uncertainty regarding the need to adjuvant radiation therapy, decision-making regarding immediate reconstruction is a challenge. Breast reconstructions by all techniques are adversely affected by radiation therapy, and many


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Surgery_Schwartz. need to adjuvant radiation therapy, decision-making regarding immediate reconstruction is a challenge. Breast reconstructions by all techniques are adversely affected by radiation therapy, and many surgeons feel reconstruction should be delayed until at least 6 months after treatment.Once the patient chooses to have immediate reconstruction, she must select a reconstructive technique. In patients selected for breast conservation, oncoplastic tissue rearrangement can be performed to minimize adverse effects of lumpectomy on breast appearance. For patients electing total mastectomy there are essentially three options: (a) tissue expansion followed by breast implant placement, (b) combined tissue flaps with breast implants, and (c) autologous tissue flaps only. After examining the patient, the surgeon then should describe those methods for which the patient is a satisfactory candidate. The patient should then be encouraged to choose based on her goals and an under-standing of the


Surgery_Schwartz

Surgery_Schwartz. the surgeon then should describe those methods for which the patient is a satisfactory candidate. The patient should then be encouraged to choose based on her goals and an under-standing of the advantages and disadvantages of each technique.Oncoplastic Breast ReconstructionBreast conservation therapy (BCT) consists of excision of the breast tumor with a surrounding margin of normal tissue com-bined with postoperative whole-breast irradiation. Although the overall survival for properly selected patients is shown to be comparable to total mastectomy and reconstruction, the breast can often be distorted and unnatural appearing after treatment. The area of the lumpectomy may create a depression with con-tour deformity, and contraction of the lumpectomy space over time can distract the nipple out of alignment and create an asym-metry with the contralateral breast. This is especially true for women with small breasts in whom a high percentage of breast volume is removed with the


Surgery_Schwartz

Surgery_Schwartz. the nipple out of alignment and create an asym-metry with the contralateral breast. This is especially true for women with small breasts in whom a high percentage of breast volume is removed with the lumpectomy.Oncoplastic surgery refers to the set of techniques devel-oped to lessen breast deformity from a partial mastectomy. One of the most common methods of minimizing adverse effects on breast appearance of is to rearrange the skin, parenchyma, and nipple location of the breast at the time of tumor extirpation using surgical techniques developed for breast aesthetic surgery. This procedure involves elevating the skin from the underlying glandular tissue, mobilizing the nipple on a vascular pedicle, and preserving as much of the vascularized glandular tissue as possible. After lumpectomy, the tissue is rearranged to shift glandular tissue into the defect and redrape the skin and nipple onto the new breast mound. After healing and completion of radiotherapy, a contralateral


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Surgery_Schwartz. lumpectomy, the tissue is rearranged to shift glandular tissue into the defect and redrape the skin and nipple onto the new breast mound. After healing and completion of radiotherapy, a contralateral conventional mastopexy or breast reduction can be performed on the contralateral side to achieve symmetry.Implant-Based ReconstructionImmediate breast reconstruction based entirely on the use of implanted devices is initially the most expedient technique. Sometimes it is possible to place a full-size implant at the time of mastectomy when the breasts are small (volume <400 cc) and the patient is a young nonsmoker with good chest wall muscula-ture. In most patients, however, a period of tissue expansion is required. The tissue expander is inserted beneath the pectoralis major and serratus anterior muscles at the time of the mastec-tomy and partially inflated. Alternatively, the tissue expander can be placed only under the pectoralis major muscle or even completely on top of the chest wall


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Surgery_Schwartz. muscles at the time of the mastec-tomy and partially inflated. Alternatively, the tissue expander can be placed only under the pectoralis major muscle or even completely on top of the chest wall muscles then covered with acellular dermal matrix directly beneath the mastectomy skin flaps. Total muscle coverage is the traditional approach, but these alternatives may be suitable only for well-selected patients. Expansion usually requires 6 to 8 weeks to complete, and an implant exchange is performed typically 3 months later. The advantages of this technique are that it involves minimum additional surgery at the time of the mastectomy, has a recovery period essentially the same of that of the mastectomy alone, and creates no additional scarring. The disadvantages of this technique are the length of time necessary to complete the entire reconstruction (up to 1 year), the requirement for a minimum of two operative procedures, and a less predictable cosmetic result due to complete reliance


Surgery_Schwartz

Surgery_Schwartz. of time necessary to complete the entire reconstruction (up to 1 year), the requirement for a minimum of two operative procedures, and a less predictable cosmetic result due to complete reliance on devices. Also, the patient awak-ens from surgery without a full-size breast and during the time of expansion must accept a breast of abnormal size and shape. Although the final shape of the breast may be satisfactory, it may lack a natural consistency due to the superficial placement of the device, especially when saline-filled implants are used. Finally, breast implants may develop late complications such as capsular contracture, infection, or extrusion. This method is ideal for a slender, small-breasted woman with minimal ptosis Brunicardi_Ch45_p1967-p2026.indd 200901/03/19 6:31 PM 2010SPECIFIC CONSIDERATIONSPART IIwho wish to avoid additional scarring and time for convales-cence. It may also be suitable for women undergoing bilateral reconstruction because symmetry is more easily


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Surgery_Schwartz. CONSIDERATIONSPART IIwho wish to avoid additional scarring and time for convales-cence. It may also be suitable for women undergoing bilateral reconstruction because symmetry is more easily achieved if both breasts are restored using the same technique. Women who elect this type of immediate reconstruction must understand that breast implants do not have an unlimited service life and that additional surgery will be likely be required to replace the breast implant at some time in the future.Tissue Flaps and Breast ImplantsThe latissimus dorsi musculocutaneous flap is the most com-mon transfer used in combination with breast implants. Other flaps may also be used, depending on patient preference and tissue availability. The principal advantage in using a tissue flap is immediate replacement of missing skin and soft tissue. In cases where there is already adequate breast skin, then a muscle only may be transferred to provide suitable implant coverage. The implant allows the final breast


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Surgery_Schwartz. of missing skin and soft tissue. In cases where there is already adequate breast skin, then a muscle only may be transferred to provide suitable implant coverage. The implant allows the final breast volume to be accurately reproduced to match the contralateral breast or, in bilateral reconstruction, adjust the breast size according to the patient’s desires. The advantages of this technique are that the implant is protected by abundant tissue, a period of tissue expansion is avoided, and the full benefit of preserving the breast skin is realized to achieve a natural-appearing breast. The disadvantage of this technique compared to implants alone is that it results in additional scarring and requires a longer period of recovery. For many patients, this approach represents an acceptable com-promise between implant-only reconstruction and autologous tissue reconstruction, incorporating some of the advantages and disadvantages of each.Autologous Tissue ReconstructionImmediate reconstruction


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Surgery_Schwartz. between implant-only reconstruction and autologous tissue reconstruction, incorporating some of the advantages and disadvantages of each.Autologous Tissue ReconstructionImmediate reconstruction using only autologous tissue is the most elaborate method of breast reconstruction but consis-tently yields the most durable, natural-appearing results. Breast implants cannot match the ability of the autologous tissue to conform to the breast skin and envelop and simulate natural breast parenchyma. The most useful flap is the transverse rec-tus abdominis musculocutaneous (TRAM) flap, although other ABPreoperativePostoperativeImmediate right DIEP FlapFigure 45-60. A. Preoperation right breast cancer. B. After mastectomy and immediate reconstruction with a DIEP flap.donor areas are also possibilities in selected cases. Autologous reconstruction is usually the best option in patients who require adjuvant radiation therapy.55The TRAM flap may be transferred to the chest using a variety of methods,


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Surgery_Schwartz. in selected cases. Autologous reconstruction is usually the best option in patients who require adjuvant radiation therapy.55The TRAM flap may be transferred to the chest using a variety of methods, depending on the circumstances of the individual patient. As a pedicled flap, it is transferred based on the superior epigastric vessels and tunneled beneath the skin to reach the mastectomy defect. As a free flap, it is based on the inferior epigastric vessels that are revascularized by micro-vascular anastomosis to vessels on the chest wall nearby the mastectomy defect. Often the microvascular technique using the deep inferior epigastric perforator (DIEP) flap is preferred because there is less risk of partial flap loss or localized areas of fat necrosis due to a more reliable blood supply (Fig. 45-60A, before operation on right breast; Fig. 45-60B, after mastectomy and immediate reconstruction with a DIEP flap). In immediate reconstruction with an axillary dissection, the axillary


Surgery_Schwartz

Surgery_Schwartz. (Fig. 45-60A, before operation on right breast; Fig. 45-60B, after mastectomy and immediate reconstruction with a DIEP flap). In immediate reconstruction with an axillary dissection, the axillary vessels are completely exposed and free of scar following the lymph node dissection in patients without previous surgery and radiation. In women being treated for recurrence with previous axillary sur-gery, the axillary vessels are less reliable, and plans should be made for the possibility of using the internal mammary vessels. The internal mammary vessels have become the most common recipient vessels for free tissue transfer in breast reconstruction in the contemporary era of sentinel lymph node biopsy that is used as a technique to perform axillary lymph node dissection in a more limited number of patients. Regardless of the technique used to transfer the tissue, the donor site is closed in a similar manner as an abdominoplasty, by repairing the abdominal wall and advancing the upper


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Surgery_Schwartz. number of patients. Regardless of the technique used to transfer the tissue, the donor site is closed in a similar manner as an abdominoplasty, by repairing the abdominal wall and advancing the upper abdominal skin downward. The umbi-licus is preserved on its vascular stalk brought to the surface through a small incision immediately above its location on the abdominal wall (Fig. 45-61A,B). Other donor sites including the buttock may be used in transferring the skin and fat supplied by the inferior gluteal artery perforator (IGAP) or the superior gluteal perforator as the main blood supply.The advantages of using this technique are complete res-toration of the breast mound in a single stage, avoidance of Brunicardi_Ch45_p1967-p2026.indd 201001/03/19 6:31 PM 2011PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-61A, B. Preand postoperative images following IGAP flap.Figure 45-62A, B. Preand postoperative images following IGAP flap, nipple reconstruction, and


Surgery_Schwartz

Surgery_Schwartz. AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-61A, B. Preand postoperative images following IGAP flap.Figure 45-62A, B. Preand postoperative images following IGAP flap, nipple reconstruction, and tattooing.ABPreoperativePostoperativeDelayed right IGAP Flappotential problems associated with breast implants, and con-sistently superior cosmetic results. The disadvantages are the magnitude of the operation, additional scarring, risks of devel-opment of abdominal bulges, and a longer period of convales-cence. Although the initial cost is greater, over the long term the total cost appears to be less because of less need for second-ary procedures to exchange implants, achieve suitable cosmetic appearance, or care for implant-related problems. This is the best operation for patients who want the most natural breast res-toration possible and who are less concerned about the amount of surgery, scarring, and recovery period.Accessory ProceduresAfter complete healing of the breast mound from the


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Surgery_Schwartz. most natural breast res-toration possible and who are less concerned about the amount of surgery, scarring, and recovery period.Accessory ProceduresAfter complete healing of the breast mound from the initial stages of reconstruction, refinements and accessory procedures may be performed at a later time to optimize the natural appear-ance of the reconstructed breast. These may include soft tissue ABBefore nipple reconstructionPostoperativeBilateral IGAP Flapmodifications of the breast mound revision, repositioning or the breast implant, scar revisions, autologous fat grafting, and nip-ple-areola complex reconstruction. A variety of methods have been described for nipple reconstruction. They are all based on local tissue rearrangements or skin grafts to create a projecting piece of skin and subcutaneous tissue that simulates the natural nipple (Fig. 45-62A,B). The pigmentation of the areola may be simulated with tattooing of colored pigments selected to match the normal coloration of


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Surgery_Schwartz. subcutaneous tissue that simulates the natural nipple (Fig. 45-62A,B). The pigmentation of the areola may be simulated with tattooing of colored pigments selected to match the normal coloration of the patient’s original anatomy.Trunk and Abdominal ReconstructionIn the torso, as in most areas of the body, the location and size of the defect and the properties of the deficient tissue determine choice of reconstructive method. A distinction is made between partial-thickness and full-thickness defects when deciding between grafts, flaps, synthetic materials, or a combina-tion of techniques. Unlike the head and the lower leg, the trunk 9Brunicardi_Ch45_p1967-p2026.indd 201101/03/19 6:31 PM 2012SPECIFIC CONSIDERATIONSPART IIharbors a relative wealth of regional transposable axial pattern flaps that allow sturdy reconstruction, only rarely requiring dis-tant free tissue transfer. Indeed, the trunk serves as the body’s arsenal, providing its most robust flaps to rebuild its largest


Surgery_Schwartz

Surgery_Schwartz. flaps that allow sturdy reconstruction, only rarely requiring dis-tant free tissue transfer. Indeed, the trunk serves as the body’s arsenal, providing its most robust flaps to rebuild its largest defects.The chest wall is a rigid framework designed to resist both the negative pressure associated with respiration and the positive pressure from coughing and from transmitted intra-abdominal forces. Furthermore, it protects the heart, lungs, and great vessels from external trauma. Reconstructions of chest wall defects must restore these functions. When a full-thick-ness defect of the chest wall involves more than four, this is usually an indication for the need for rigid chest wall recon-struction usually using synthetic meshes made of polypropyl-ene, polyethylene, or polytetrafluoroethylene, which may be reinforced with polymethylmethacrylate acrylic. In contami-nated wounds, biologic materials are preferred, such as acel-lular dermal matrix allografts. For soft tissue restoration, the


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Surgery_Schwartz. which may be reinforced with polymethylmethacrylate acrylic. In contami-nated wounds, biologic materials are preferred, such as acel-lular dermal matrix allografts. For soft tissue restoration, the pectoralis major muscle is commonly used as a pedicled flap for coverage of the sternum, upper chest, and neck. It may be mobilized and transferred on a vascular pedicle based on the pectoral branch of the thoracoacromial artery or a vascular supply based on perforators from the internal mammary ves-sels. Either flap design is useful in covering the sternum after dehiscence or infection occurring as a complication of median sternotomy or with sternal resection for tumor extirpation. For the lower third of the sternum, a rectus abdominis muscle flap based on the superior epigastric vessels or the deep inferior epigastric vessels is useful. If based on the inferior blood sup-ply, it must be transferred as a free flap with recipient vessels outside of the zone in injury. The latissimus dorsi


Surgery_Schwartz

Surgery_Schwartz. deep inferior epigastric vessels is useful. If based on the inferior blood sup-ply, it must be transferred as a free flap with recipient vessels outside of the zone in injury. The latissimus dorsi musculocu-taneous flap is useful for chest wall reconstructions in places other than the anterior midline. Similar to the pectoralis major muscle, it may be transferred on either a single blood supply that is based on the thoracodorsal vessels from the subscapular system or on vessels perforating from deeper source vessels near to the posterior midline. The serratus anterior muscle can be included on the same vascular pedicle to further increase its surface area. Finally, the trapezius muscle flap, based on the transverse cervical vessels, is generally used as a pedicled flap to cover the upper midback, base of neck, and shoulder. The superior portion of the muscle along with the acromial attach-ment and spinal accessory nerve must be preserved to maintain normal shoulder elevation


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Surgery_Schwartz. upper midback, base of neck, and shoulder. The superior portion of the muscle along with the acromial attach-ment and spinal accessory nerve must be preserved to maintain normal shoulder elevation function.The abdominal wall also protects the internal vital organs from trauma, but with layers of strong torso-supporting mus-cles and fascia rather than with osseous structures. The goals of reconstruction are restoration of structural integrity, prevention of visceral herniation, and provision of dynamic muscular sup-port. Although abdominal wall defects may occur in association with oncologic tumor resections, the most common etiology is fascial dehiscence after laparotomy. When a reconstruction plan is being formulated, careful physical examination and review of the medical history will help prevent selection of an otherwise sound strategy that, because of previous incisions and trauma, is destined for failure.Superficial defects of the abdominal skin and subcutane-ous tissue are


Surgery_Schwartz

Surgery_Schwartz. help prevent selection of an otherwise sound strategy that, because of previous incisions and trauma, is destined for failure.Superficial defects of the abdominal skin and subcutane-ous tissue are usually easily controlled with skin grafts, local advancement flaps, or tissue expansion. Defects of the under-lying musculofascial structures are more difficult to manage. The abdominal wall fascia requires a minimal-tension closure to avoid dehiscence, recurrent incisional hernia formation, or abdominal compartment syndrome. Prosthetic meshes are frequently used to replace the fascia in clean wounds and in operations that create myofascial defects. When the wound is contaminated, as in infected mesh reconstructions, enterocuta-neous fistulas, or viscus perforations, prosthetic mesh is avoided because of the risk of infection. The technique of component separation procedure has proven beneficial for closing large midline defects with autologous tissue and avoiding prosthetic materials. This


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Surgery_Schwartz. of the risk of infection. The technique of component separation procedure has proven beneficial for closing large midline defects with autologous tissue and avoiding prosthetic materials. This procedure involves advancement of bilateral flaps composed of the anterior rectus fascia rectus and oblique muscles after lateral release. Midline defects measuring up to 10 cm superiorly, 18 cm centrally, and 8 cm inferiorly can be closed using this method.Techniques based on rearranging and reinforcing abdomi-nal wall elements might be inadequate for extremely large or full-thickness abdominal wall defects. For these defects, regional flaps or free flaps are required. Pedicled flaps from the thigh are useful, such as the tensor fasciae latae pedicled flap, based on the ascending branch of the lateral circumflex femoral vessels, or the anterolateral thigh flap, based on the descending branch of the lateral circumflex vessels. Bilateral flaps might be required.Pelvic ReconstructionAnother


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Surgery_Schwartz. lateral circumflex femoral vessels, or the anterolateral thigh flap, based on the descending branch of the lateral circumflex vessels. Bilateral flaps might be required.Pelvic ReconstructionAnother important area for consideration of reconstructive surgical procedures is in the perineum.56 The perineal region is part of the specialized part of the trunk that supports the pelvic outlet lying between the pubic symphysis, the coccyx, the inferior rami of the pubis, and the ischial tuberosities. Sup-port is provided by the urogenital diaphragm, the deep and superficial fasciae, and the skin. Specialized anatomic struc-tures pass through the perineum. Posteriorly is the anus, and anteriorly are the genitalia and urethra. Treatment of tumors involving this area often require a combination of surgery and radiation. The resulting loss of tissue and healing impairment coupled with the nonyielding nature of the bony pelvic outlet can result in unique reconstructive requirements that often are


Surgery_Schwartz

Surgery_Schwartz. and radiation. The resulting loss of tissue and healing impairment coupled with the nonyielding nature of the bony pelvic outlet can result in unique reconstructive requirements that often are best addressed with tissue transfer. The reconstruction must achieve wound healing and restore support to the pelvic con-tents, accommodate urinary and bowel function, and finally restore the penis in men and the vagina and vulva in women. Local flaps, regional flaps, or free tissue transfer all have pos-sible application depending on the extent of the resection and local tissue compromise.Other Clinical CircumstancesBesides trauma and cancer, other etiologies can cause functional and cosmetic deformities due to tissue impairment for which reconstructive surgery has value. These include pressure sores, diabetic foot ulcers, and lymphedema.Pressure Sores. A pressure ulcer is defined as tissue injury caused by physical pressure applied to the tissues from an exter-nal source at a magnitude that


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Surgery_Schwartz. diabetic foot ulcers, and lymphedema.Pressure Sores. A pressure ulcer is defined as tissue injury caused by physical pressure applied to the tissues from an exter-nal source at a magnitude that exceeds capillary perfusion pres-sure. Prolonged tissue ischemia leads to local tissue necrosis. Pressure ulcers tend to occur in people debilitated by advanced age, chronic illness, poor nutrition, prolonged immobilization, motor paralysis, or inadequate sensation. Spinal cord injury patients are especially prone to developing pressure sores. Pres-sure sores can also occur in healthy individuals who undergo prolonged surgical operations and parts of the body support-ing the weight of the patient on the operating table (e.g., the occiput, the sacral prominence, the heels of the feet) are improp-erly padded.57Brunicardi_Ch45_p1967-p2026.indd 201201/03/19 6:31 PM 2013PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Pressure sores are an important contributor to morbidity in patients suffering from


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Surgery_Schwartz. padded.57Brunicardi_Ch45_p1967-p2026.indd 201201/03/19 6:31 PM 2013PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Pressure sores are an important contributor to morbidity in patients suffering from limited mobility. Most can be prevented by diligent nursing care in an attentive, cooperative patient. Preventing pressure ulcers requires recognition of susceptible and utilizing appropriate measures to reduce pres-sure on areas of the body at risk. This involves frequent position changes while sitting or supine and the use of pressure-reducing medical equipment such as low-air-loss mattresses and seat cushions and heel protectors. Malnourishment, poor glucose control in diabetics, poor skin hygiene, urinary or bowel incon-tinence, muscle spasms, and joint contractures all increase the risk of pressure sore formation. Mitigating these factors is essential before embarking on a complex reconstructive treat-ment plan. Successful reconstruction also requires a cooperative and motivated


Surgery_Schwartz

Surgery_Schwartz. of pressure sore formation. Mitigating these factors is essential before embarking on a complex reconstructive treat-ment plan. Successful reconstruction also requires a cooperative and motivated patient with good social support.Surgical treatment of pressure ulcers is based on wound depth. The staging system is summarized in Fig. 45-63.58 Stage I and II ulcers are treated nonsurgically with local wound care and interventions to relieve pressure on the affected area. Patients with stage III or IV ulcers should be evaluated for surgery. Important features for preoperative assessment include the extent of soft tissue infection, the presence of con-taminated fluid collection or abscess, osteomyelitis, and com-munication with deep spaces (e.g., joint space, urethra, colon, or spinal canal). Laboratory blood tests and imaging studies help establish whether soft tissue or bone infection is present. Plain radiographs are usually adequate to rule out osteomyeli-tis; CT and MRI are helpful


Surgery_Schwartz

Surgery_Schwartz. Laboratory blood tests and imaging studies help establish whether soft tissue or bone infection is present. Plain radiographs are usually adequate to rule out osteomyeli-tis; CT and MRI are helpful when plain films are equivocal. Necrotic tissue and abscesses should be surgically debrided without delay to prevent or treat systemic sepsis. Bone must also be excised if it appears involved, as evidenced by poor bleeding, softness, or frank purulence. Patients with high spinal cord injuries at or above the level of the fifth thoracic vertebra may experience sudden extreme elevation of blood pressure, an 10Stage 1Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area of the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin,


Surgery_Schwartz

Surgery_Schwartz. skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer may appear with persistent red, blue of purple hues.Stage 2Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.Stage 3Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlaying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.Stage 4Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule). Undermining and sinus tracts may also be associated with Stage 4 pressure ulcers.ABCD Figure 45-63. The staging system for pressure


Surgery_Schwartz

Surgery_Schwartz. or supporting structures (for example, tendon or joint capsule). Undermining and sinus tracts may also be associated with Stage 4 pressure ulcers.ABCD Figure 45-63. The staging system for pressure sores.autonomic-mediated event called hyperreflexia. This condition must be immediately recognized and treated to prevent intra-cranial and retinal hemorrhage, seizures, cardiac irregularities, and death.After adequate debridement, the pressure ulcer can be treated nonsurgically in patients who have shallow wounds with healthy surrounding tissues capable of healing secondarily with offloading pressure. Nonsurgical treatment is also best in patients for whom surgery is contraindicated because of previ-ous surgery or comorbidities. For surgical candidates, primary closure is rarely performed because an inadequate amount of quality surrounding tissue prevents closure without tension, making the repair predisposed to failure. Split-thickness skin grafting can be useful for shallow ulcers with


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Surgery_Schwartz. an inadequate amount of quality surrounding tissue prevents closure without tension, making the repair predisposed to failure. Split-thickness skin grafting can be useful for shallow ulcers with well-vascularized wound beds on which shear forces and pressure can be avoided after repair, a rare circumstance in most patients with pressure ulcers.The mainstay of surgical treatment is tissue transfer fol-lowing several guiding principles. Local muscle or musculocu-taneous flaps are suitable for areas of heavy contamination and complex wound surface contours. Durability requires the ability to consistently off-load of the area of reconstruction postopera-tively. Fasciocutaneous flaps afford more durable reconstruc-tion when off-loading is not possible. The anatomic location is an important determinant of flap choice. Once a donor site is selected, a flap of adequate size is designed and transferred in a way that avoids suture lines in the area under pressure. Large flaps also permit


Surgery_Schwartz

Surgery_Schwartz. determinant of flap choice. Once a donor site is selected, a flap of adequate size is designed and transferred in a way that avoids suture lines in the area under pressure. Large flaps also permit readvancement if the patient experiences a recurrent ulcer in the same area. Sacral pressure sores may be managed with fasciocutaneous or musculocutaneous flaps based on the gluteal vessels. Ischial pressure sores may be man-aged with gluteal flaps or flaps transferred from the posterior thigh, such as the posterior thigh flap based on the descend-ing branch of the inferior gluteal artery. Trochanteric ulcers Brunicardi_Ch45_p1967-p2026.indd 201301/03/19 6:31 PM 2014SPECIFIC CONSIDERATIONSPART IIFigure 45-64. Flap reconstruction of pressure ulcers. Top row: Preoperative and 1-month postoperative photos of a stage IV sacral decubitus ulcer treated with a myocutaneous gluteus maximus flap. Bottom row: Preoperative and 1-month postoperative photos of a stage IV trochan-teric ulcer treated


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Surgery_Schwartz. photos of a stage IV sacral decubitus ulcer treated with a myocutaneous gluteus maximus flap. Bottom row: Preoperative and 1-month postoperative photos of a stage IV trochan-teric ulcer treated with a myocutaneous V-Y tensor fasciae latae flap.may be managed with musculocutaneous flaps based on the tensor fasciae latae, rectus femoris, or vastus lateralis muscles (Fig. 45-64). The obligatory loss of motor function associated with using these flaps adds no additional functional impairment in patients already paralyzed as a result of strokes or spinal cord injuries.Proper postoperative care after flap reconstruction of pressure ulcers is critical for success. Low-pressure, air fluid-ized beds help to off-load the affected area and prevent new areas of involvement during the first 7 to 10 days of healing. Other important measures are adequate nutritional support and medications to prevent muscle spasms. Careful coordination with patient care providers is planned preoperatively in order


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Surgery_Schwartz. of healing. Other important measures are adequate nutritional support and medications to prevent muscle spasms. Careful coordination with patient care providers is planned preoperatively in order to avoid gaps in care that can lead to early recurrent ulceration. Care of the pressure ulcer patient is a labor-intensive process that requires attention to detail by the surgeon, nurses, thera-pists, caseworkers, and family.Diabetic Foot Ulceration. The pathophysiology of primary diabetic lower limb complications has three main components: (a) peripheral neuropathy (motor, sensory, and autonomic), (b) peripheral vascular disease, and (c) immunodeficiency. Altered foot biomechanics and gait caused by painless col-lapse of ligamentous support, foot joints, and foot arches change weight-bearing patterns. Blunted pain allows cutane-ous ulceration to begin. With breakdown of the skin barrier function, polymicrobial infections become established. Bac-terial invasion is often fostered by poor


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Surgery_Schwartz. patterns. Blunted pain allows cutane-ous ulceration to begin. With breakdown of the skin barrier function, polymicrobial infections become established. Bac-terial invasion is often fostered by poor blood supply due to peripheral vascular disease coupled with microangiopathy. Finally, local host defenses may be less effective in resisting bacteria because of poor blood supply and impaired cellular function. Cutaneous ulcerations may progress painlessly to involve deeper soft tissues and bone. The ultimate endpoint of this process is such severe tissue damage that extremity amputation is the only treatment remaining. More than 60% of nontraumatic lower extremity amputations occur in diabetics. The age-adjusted lower extremity amputation rate in diabet-ics (5.0 per 1000 diabetics) was approximately 28 times that of people without diabetes (0.2 per 1000 people).59 Improved patient education and medical management, early detection of foot problems, and prompt intervention play important


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Surgery_Schwartz. 28 times that of people without diabetes (0.2 per 1000 people).59 Improved patient education and medical management, early detection of foot problems, and prompt intervention play important roles in improving the chances of limb preservation.60The best approach to managing diabetic patients with lower extremity wounds is to involve a multidisciplinary team composed of a plastic and reconstructive surgeon, a vascular surgeon, an orthopedic surgeon, a podiatrist, an endocrinolo-gist specializing in diabetes, a nutritionist, and a physical or Brunicardi_Ch45_p1967-p2026.indd 201401/03/19 6:31 PM 2015PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45occupational therapist. This brings together the greatest level of expertise to manage bone and soft tissue issues as well as the underlying disease and medical comorbidities. Treatment begins with rigorous control of blood glucose levels and a thor-ough assessment of comorbidities. In addition to careful detail-ing of the extent of the wound


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Surgery_Schwartz. and medical comorbidities. Treatment begins with rigorous control of blood glucose levels and a thor-ough assessment of comorbidities. In addition to careful detail-ing of the extent of the wound and the tissues involved, physical examination documents sensory deficits and vascular status. Plain radiographs, MRI, bone scintigraphy, and angiography or duplex Doppler ultrasound imaging may be indicated. A patient with significant vascular disease may be a candidate for lower extremity endovascular revascularization or open bypass.61 Nerve conduction studies may diagnose surgically reversible neuropathies at compressive sites and aid in decisions about whether to perform sensory nerve transfers to restore plantar sensibility.60 Antibiotic and fungal therapies should be guided by tissue culture results.Surgical management starts with debridement of devital-ized tissues. Methods of wound closure are dictated by the extent and location of the remaining defect. Negative pressure wound


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Surgery_Schwartz. culture results.Surgical management starts with debridement of devital-ized tissues. Methods of wound closure are dictated by the extent and location of the remaining defect. Negative pressure wound dressings may be appropriate for superficial defects in an effort to allow secondary healing or as a temporizing measure until definitive wound closure can be achieved. Skin grafts might be indicated at times but cannot be expected to provide durable cov-erage in weight-bearing or high-shear areas. Local and regional flaps can be considered if the extremity is free of significant occlusive peripheral vascular or combined with vascular bypass. Microvascular free tissue transfers are appropriate when defects are large or when local flaps are not available. Combination lower extremity bypass and free flap coverage has proved benefi-cial for the treatment of the diabetic foot in terms of healing and reduction of disease progression (Table 45-6). Consultation with a podiatrist or an orthopedic


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Surgery_Schwartz. free flap coverage has proved benefi-cial for the treatment of the diabetic foot in terms of healing and reduction of disease progression (Table 45-6). Consultation with a podiatrist or an orthopedic surgeon who specializes in foot and ankle problems can be considered to improve foot biomechanics and manage bony prominences that act as pressure points on the soft tissue to reduce the risk of recurrent ulceration. Proper foot-wear (including orthotic devices and off-loading shoe inserts), hygiene, and toenail and skin care are essential.60Lymphedema. Lymphedema is the abnormal accumulation of protein-rich fluid in the interstitial spaces of the tissues. It is a complex disorder with both congenital and acquired causes. No universally effective remedy has been devised, but a variety of treatment methods including reconstructive surgery have been effective in carefully selected patients.It is important to be familiar with the fundamentals of lymph physiology in order to understand the


Surgery_Schwartz

Surgery_Schwartz. methods including reconstructive surgery have been effective in carefully selected patients.It is important to be familiar with the fundamentals of lymph physiology in order to understand the rationale for the various forms of lymphedema treatment. Lymph fluid is formed at the capillary level where there is a net outflow of fluid and serum proteins from the intravascular space into the intersti-tium. In the average adult, this amounts to approximately 3 liters of fluid daily. Open-ended lymph capillaries collect this fluid where the lymphatic endothelial cells form loose intercellular connections that freely allow fluid to enter. From here, the net-work of specialized vascular structures gathers the extravasated fluid and transports it back into central circulation. The system is a high-volume transport mechanism that clears proteins and lipids from the interstitial space primarily by means of differ-ential pressure gradients. Lymph fluid enters the lymph vessels driven by colloid and


Surgery_Schwartz

Surgery_Schwartz. transport mechanism that clears proteins and lipids from the interstitial space primarily by means of differ-ential pressure gradients. Lymph fluid enters the lymph vessels driven by colloid and solute concentration gradients at the capil-lary level. Flow is sustained in the larger vessels through direct contractility of the lymph vessel walls and by indirect compres-sion from surrounding skeletal muscle activity. Throughout the system, one-way valves prevent reverse flow. The lymphatic vessels course throughout the body alongside the venous sys-tem, into which they eventually drain via the major thoracic and cervical ducts at the base of the neck.Under normal conditions, there is a balance between fluid formation and lymph transport capacity. With congenital hypo-plasia or acquired obstruction, there is a reduction in transport capacity resulting in accumulation of fluid and protein in the interstitium. Localized fluid stagnation, hypertension, and valvu-lar incompetence further


Surgery_Schwartz

Surgery_Schwartz. there is a reduction in transport capacity resulting in accumulation of fluid and protein in the interstitium. Localized fluid stagnation, hypertension, and valvu-lar incompetence further degrade transport capacity and acceler-ate lymph fluid accumulation edema. Dissolved and suspended serum proteins, cellular debris, and waste products of metabolism elicit an inflammatory response with associated with fibrovas-cular proliferation and collagen deposition leading to firm, non-pitting swelling characteristic of chronic, long-standing edema. Lymphoscintigraphy can help detail the lymphatic anatomy and quantify lymphatic flow. MRI can provide additional informa-tion about the larger caliber lymphatic vessels, possibly helping to identify specific points of obstruction.Primary lymphedema is caused by congenital hypopla-sia and is classified clinically based on the age of the affected individual when swelling first appears. Lymphedema present at birth is an autosomal dominant disorder


Surgery_Schwartz

Surgery_Schwartz. is caused by congenital hypopla-sia and is classified clinically based on the age of the affected individual when swelling first appears. Lymphedema present at birth is an autosomal dominant disorder sometimes referred to as Milroy’s disease. Lymphedema praecox occurs near the time of puberty but can appear up to age 35. This form tends to occur in females and usually affects the lower extremity. It accounts for more than 90% of cases. Finally, lymphedema tarda appears after the age of 35 years and is relatively rare.Secondary lymphedema is the acquired form of the dis-order and is more common than congenital causes. Worldwide the most common etiology is parasitic infestation with filarial, a highly specialized nematode transmitted by blood-eating insects Table 45-6Some reconstructive options for the diabetic footAREA OF DEFECTRECONSTRUCTIVE OPTIONSForefootV-Y advancementToe island flapSingle toe amputationLisfranc’s amputationMidfootV-Y advancementToe island flapMedial plantar artery


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Surgery_Schwartz. for the diabetic footAREA OF DEFECTRECONSTRUCTIVE OPTIONSForefootV-Y advancementToe island flapSingle toe amputationLisfranc’s amputationMidfootV-Y advancementToe island flapMedial plantar artery flapFree tissue transferTransmetatarsal amputationHindfootLateral calcaneal artery flapReversed sural artery flapMedial plantar artery flap ± flexor digitorum brevisAbductor hallucis muscle flapAbductor digiti minimi muscle flapFree tissue transferSyme’s amputationFoot dorsumSupramalleolar flapReversed sural artery flapThinner free flaps (e.g., temporoparietal fascia, radial forearm, groin, thinned anterolateral thigh flaps)Brunicardi_Ch45_p1967-p2026.indd 201501/03/19 6:31 PM 2016SPECIFIC CONSIDERATIONSPART IIFigure 45-65. Algorithm for lymphedema management.YesNoYesNoYesNoSymptomatic LymphedemaAmenable to physiologic lymphatic procedures?Suitable lymphatic vessels on MRL or ICGL for LVA?Secondary to surgery and/or XRT?LVA ±VLNTLiposuction ±excisionLVAonlyVLNTonlyConsider furtherLVA or


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Surgery_Schwartz. to physiologic lymphatic procedures?Suitable lymphatic vessels on MRL or ICGL for LVA?Secondary to surgery and/or XRT?LVA ±VLNTLiposuction ±excisionLVAonlyVLNTonlyConsider furtherLVA or VLNTInadequate response?Secondary to surgery and/or XRT?Severe functional impairment?Excess soft tissue? Skin changes?Yes• Responsive to nonsurgical therapy, but symptoms plateaued or worsening• Significant pitting edemaNo• Minimal or no improvement with nonsurgical therapy• Minimal to absent pitting edemafound mostly in developing countries. In nonaffected areas of the world, the most common cause of secondary lymphedema is regional lymphatic vessel destruction associated with can-cer treatment. It often occurs in the upper extremity of women treated with surgery and radiation therapy for breast cancer. In the lower extremities, it is associated with neoplasms treated with inguinal or retroperitoneal lymph node dissection.The goal of lymphedema treatment is to minimize func-tional and cosmetic


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Surgery_Schwartz. In the lower extremities, it is associated with neoplasms treated with inguinal or retroperitoneal lymph node dissection.The goal of lymphedema treatment is to minimize func-tional and cosmetic disability caused by chronic enlargement and to prevent infection of the involved extremity. The foun-dations of management are patient education and nonsurgical interventions, which include limb elevation, external compres-sive garments and devices, and manual lymphatic massage, sometimes referred to as complex decongestive physiother-apy. The patient must use protective gloves or garments when engaged in activities that might cause minor skin injury, such as gardening, smoking cigarettes, and cooking. Interstitial lymph fluid is prone to infection. When signs of infection appear, prompt treatment that often includes hospitalization with intravenous antibiotics is essential to prevent severe infection and further destruction of remaining lymphatic sys-tem and worsening of lymphedema.When


Surgery_Schwartz

Surgery_Schwartz. that often includes hospitalization with intravenous antibiotics is essential to prevent severe infection and further destruction of remaining lymphatic sys-tem and worsening of lymphedema.When nonsurgical methods fail, surgery can be consid-ered as a treatment option. Surgical operations for lymphedema are either ablative, designed to remove excess lymphedematous tissues, or reconstructive, intended to restore lymph function and improve transport capacity. These choices are presented in Fig. 45-65. Ablative procedures range from minimally invasive measures such as suction lipectomy to complete excision of skin and subcutaneous tissue down to muscle fascia with split-thickness skin grafting. Contemporary reconstructive procedures establish new connections between the venous and lymphatic systems somewhere proximal to the point of obstruction. A variety of methods have been described, including lympholymphatic, lym-phovenous, lymph node venous anastomoses, and vascularized lymph node


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Surgery_Schwartz. systems somewhere proximal to the point of obstruction. A variety of methods have been described, including lympholymphatic, lym-phovenous, lymph node venous anastomoses, and vascularized lymph node transfer. Each of these procedures can yield suc-cess, and it has become clear that patient selection is perhaps the most important aspect of surgical care because the patient must be matched to the procedure most likely to yield improved con-trol of swelling and prevent infection. Reconstructive surgery is not generally a cure for the condition, but rather it is intended to ease management challenges and reduce the risks of infection. After surgery, continued use of nonsurgical techniques is still required for optimal results.AESTHETIC SURGERY AND MEDICINEAesthetic, or cosmetic, surgery is an important part of the spe-cialty of plastic surgery. The American Medical Association defines cosmetic surgery as “surgery performed to reshape normal structures of the body to improve the patient’s


Surgery_Schwartz

Surgery_Schwartz. important part of the spe-cialty of plastic surgery. The American Medical Association defines cosmetic surgery as “surgery performed to reshape normal structures of the body to improve the patient’s appear-ance and self-esteem.” It is a natural extension of surgical tech-niques for tissue modification traditionally developed for other reasons. Because aesthetic surgery primarily relates to personal appearance and attractiveness and not a particular disease pro-cess, there has been a tendency to dismiss the health value of Brunicardi_Ch45_p1967-p2026.indd 201601/03/19 6:31 PM 2017PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45aesthetic surgery. Nevertheless, personal appearance plays an important role in psychosocial health. Physical attractiveness plays a role in the marketplace with well-documented influence on employment opportunities, advancement, and earnings.62 The multibillion industry of products and services designed to opti-mize appearance, which spans a wide spectrum


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Surgery_Schwartz. well-documented influence on employment opportunities, advancement, and earnings.62 The multibillion industry of products and services designed to opti-mize appearance, which spans a wide spectrum between simple cosmetics to elaborate surgical procedures, bears testament to the perceived value by the general population.Important work demonstrates a link between aesthetic sur-gery and psychosocial health. Surgery performed on the face,63 nose,64 ears,65 breast,66 and body67 can positively affect quality of life on multiple scales. There is a clear association between one’s personal appearance and success in the marketplace. As the primary benefits of aesthetic surgery are related to the psy-chosocial outcomes, it is important to assess the state of psycho-logical health prior to offering aesthetic surgery. A variety of preoperative psychological comorbidities can adversely affect outcomes, most notably a syndrome known as body dysmor-phic disorder,68 present in individuals who manifest


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Surgery_Schwartz. surgery. A variety of preoperative psychological comorbidities can adversely affect outcomes, most notably a syndrome known as body dysmor-phic disorder,68 present in individuals who manifest a preoccu-pation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.69 Performing a surgical procedure to modify personal appearance in such an individual is associated with a high risk of a poor outcome.It is important for all surgeons to have an appreciation of the methods of patient evaluation, surgical techniques, and typical outcomes that might be anticipated in aesthetic sur-gery. Patients seek aesthetic surgery when they are unable to achieve a personal standard of physical appearance without sur-gical modification of various body parts that most affect their appearance. This is especially true for features that are visible in public and strong determinants of appearance, such as the face, breasts, abdomen, and buttocks.


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Surgery_Schwartz. body parts that most affect their appearance. This is especially true for features that are visible in public and strong determinants of appearance, such as the face, breasts, abdomen, and buttocks. The etiology of undesir-able characteristics of form or skin quality can be familial or acquired through natural processes of aging, injury, cancer, or degeneration. Unwanted changes in appearance that result from these processes may still fall within the range of normal appearance yet fall short of the patient’s personal aesthetic ideal. Patient assessment requires an understanding of personal and cultural ideals of appearance. The surgeon must be knowledge-able about the various surgical and nonsurgical techniques that might be considered to address the patient’s concerns.In practical terms, there are both reconstructive and cos-metic elements to almost every plastic surgery case, and the def-inition of “normal” structure is sometimes very subjective and difficult to quantify.


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Surgery_Schwartz. terms, there are both reconstructive and cos-metic elements to almost every plastic surgery case, and the def-inition of “normal” structure is sometimes very subjective and difficult to quantify. Nevertheless, there are patients for whom it is a priority to make surgical changes to their bodies in the clear absence of a functional deformity. Aesthetic surgery patients present a unique challenge to the plastic surgeon because the most important outcome parameter is not truly appearance, but patient satisfaction. Optimally, a good cosmetic outcome will be associated with a high level of patient satisfaction. For this to be the case, the plastic surgeon must do a careful analysis of the patient’s motivations for wanting surgery, along with the patient’s goals and expectations. The surgeon must make a rea-sonable assessment that the improvements that can be achieved through surgery will meet the patient’s expectations. The sur-geon must appropriately counsel the patient about the


Surgery_Schwartz

Surgery_Schwartz. must make a rea-sonable assessment that the improvements that can be achieved through surgery will meet the patient’s expectations. The sur-geon must appropriately counsel the patient about the magni-tude of the recovery process, the exact location of scars, and potential complications. If complications do occur, the surgeon must manage these in a manner that preserves a positive doctor-patient relationship.Figure 45-66. Incisions for cervicofacial rhytidectomy.Aesthetic Surgery of the FaceA thorough evaluation of the patient who presents for facial aes-thetic surgery begins with acquiring a clear understanding of the patient’s primary concern regarding appearance. Examination focuses on that region but takes into consideration overall facial appearance that might be contributing to the patient’s concerns but of which the patient is unaware. The skin quality is care-fully assessed as well as the location, symmetry, and position of each critical feature of facial appearance such as


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Surgery_Schwartz. patient’s concerns but of which the patient is unaware. The skin quality is care-fully assessed as well as the location, symmetry, and position of each critical feature of facial appearance such as scalp hairline, forehead length, eyebrow shape and position, eyelid configu-ration, nasal proportions, and shape of the lips. Overall facial proportions are assessed, such as the prominence of the orbital rims and malar areas, the chin projection, and contours along the margin of the mandible. An appropriately performed facelift can yield an aesthetically pleasing result (Fig. 45-66).A variety of procedures have been described for modify-ing facial appearance. Nonsurgical interventions topical treat-ments of the skin surface include chemical and laser facial peels. Injections of biocompatible materials made of processed biologic proteins (e.g., collagen, hyaluronic acid) or synthetic materials such as polymethylmethacrylate can modify the depth of facial wrinkles and fullness of facial


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Surgery_Schwartz. materials made of processed biologic proteins (e.g., collagen, hyaluronic acid) or synthetic materials such as polymethylmethacrylate can modify the depth of facial wrinkles and fullness of facial structures such as the lips. Appearance can also be modified using neuromodulators to block facial muscle function to reduce undesirable move-ments of facial landmarks or deepening of facial wrinkles. Sur-gical interventions may be employed when the structure and position of facial features require modifications greater than what may be achieved with nonsurgical procedures. Browlift operations raise the position of the eyebrows (Fig. 45-67). Blepharoplasty is a set of procedures that modify the shape and position of the upper and lower eyelids. Facelift modifies the configuration and amount of facial skin and subcutaneous Brunicardi_Ch45_p1967-p2026.indd 201701/03/19 6:31 PM 2018SPECIFIC CONSIDERATIONSPART IIstructures to correct features such as deep nasolabial folds, skin redundancy


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Surgery_Schwartz. facial skin and subcutaneous Brunicardi_Ch45_p1967-p2026.indd 201701/03/19 6:31 PM 2018SPECIFIC CONSIDERATIONSPART IIstructures to correct features such as deep nasolabial folds, skin redundancy along the inferior border of the mandible, and loss of definition of neck contours. Rhinoplasty involves a complex set of procedures to modify the size, shape, and airway function of the nose (Fig. 45-68).Aesthetic Surgery of the BreastSurgery to modify the shape, volume, and nipple position of the breast are among the most common aesthetic procedures. Figure 45-67. Facelift. A. Preoperative appearance. B. Postopera-tive appearance.ABBreast reduction surgery reduces the amount of both skin and breast tissue volume and modifies the position of the nipple on the breast mound (Fig. 45-69). The most common indication is to treat symptoms of large breasts known as macromastia, which is associated with a symptomatic triad of upper back pain, bra strap grooving, and skin rashes under the fold of


Surgery_Schwartz

Surgery_Schwartz. common indication is to treat symptoms of large breasts known as macromastia, which is associated with a symptomatic triad of upper back pain, bra strap grooving, and skin rashes under the fold of the breasts. Unilateral breast reduction is often performed to achieve breast symmetry after contralateral postmastectomy breast reconstruc-tion. As with all breast surgery, achieving a natural and cos-metically acceptable appearance is essential to a satisfactory outcome. Mastopexy techniques share many aspects with breast reduction except that breast volume is preserved and only the amount of skin and location of the nipple are modified. Funda-mental to the success of the procedure is the establishment of symmetric and proper nipple position. Nipple ptosis is graded by the nipple position relative to the inframammary fold.Many patients seek surgical intervention to increase breast size in a procedure known as augmentation mammoplasty (Fig. 45-70). Breast volume is increased by insertion


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Surgery_Schwartz. to the inframammary fold.Many patients seek surgical intervention to increase breast size in a procedure known as augmentation mammoplasty (Fig. 45-70). Breast volume is increased by insertion of a syn-thetic implant specifically designed for this purpose. Modern breast implants are manufactured from various formulations of silicone polymers. The implant shell, which is on contact with the tissues, is always made from silicone elastomer. The filling material can be either silicone or saline, depending on the patient and surgeon preference. As with any surgical proce-dure that involves implanting synthetic materials, the surgeon must fully understand the nature of the materials and be able to inform the patient of all known risks and benefits.The pervasive risk of breast cancer among women man-dates careful consideration of the impact of any breast surgery on cancer screening, diagnosis, and treatment. Preoperative breast cancer screening consistent with current American Can-cer


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Surgery_Schwartz. women man-dates careful consideration of the impact of any breast surgery on cancer screening, diagnosis, and treatment. Preoperative breast cancer screening consistent with current American Can-cer Society guidelines should be performed for all patients undergoing elective breast reshaping surgery. After breast augmentation surgery, routine screening mammograms are no longer considered adequate. Patients with breast implants must have diagnostic mammograms where a radiologist studies the images at the time of the study to ensure they completely visual-ize the breast tissue.Gynecomastia is a condition of excess breast tissue in males. It can be caused by a wide range of medical disorders, including liver dysfunction, endocrine abnormalities, genetic syndromes (e.g., Klinefelter’s syndrome), renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast


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Surgery_Schwartz. renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast enlargement include marijuana use, digoxin, spironolactone, cimetidine, the-ophylline, diazepam, and reserpine. Although all of these pos-sible causes must be considered in any patient presenting with gynecomastia, the majority of patients have idiopathic enlarge-ment of the breast parenchyma, often occurring in teenagers. Surgical correction of this condition as often indicated.Aesthetic Surgery of the BodyAesthetic surgery may be applied to the torso and extremities. The most common circumstance is following massive weight loss, typically as a result of bariatric surgery. Morbid obesity stretches the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour


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Surgery_Schwartz. the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour deformities. Improvement can be achieved only through skin excision. Therefore, all body-contouring surgery Brunicardi_Ch45_p1967-p2026.indd 201801/03/19 6:31 PM 2019PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ANaso-frontal angleNaso-labial angleTip-columellar angleLower lateral cartilageUpper lateral cartilageBCFigure 45-68. A. Rhinoplasty anatomy. B. Preoperative appear-ance. C. Postoperative appearance.Brunicardi_Ch45_p1967-p2026.indd 201901/03/19 6:31 PM 2020SPECIFIC CONSIDERATIONSPART IIFigure 45-69. Inferior pedicle reduction mammaplasty.De-epithelializedareaExcised arearepresents a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the


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Surgery_Schwartz. a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the procedures. With the increased number of bar-iatric surgery procedures over the past decade, body-contouring surgery has become very popular and is emerging as a new sub-specialty of plastic surgery.Excess skin and subcutaneous tissue on the anterior abdominal wall creates a redundancy that can hang over the pubic area called an abdominal wall pannus. It can cause dif-ficulty dressing and maintaining proper personal hygiene. A panniculectomy is a procedure that removes the redundant skin and subcutaneous tissue of the pannus. If additional contouring of the abdominal wall is performed, the procedure is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires


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Surgery_Schwartz. is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires tightening of the underlying abdominal wall by suturing the midline and transposing the umbilicus as the upper abdominal skin is advanced inferiorly. At times additional skin must be excised transversely, requiring a concurrent vertical incision to remove skin in two vectors (Fig. 45-71). Possible complications include skin necrosis, persistent paresthesias of the abdominal wall, seroma, and wound separation. Necrosis of the umbili-cus may complicate preservation of that structure if the stalk is excessively long or an umbilical hernia is repaired. Adding a Brunicardi_Ch45_p1967-p2026.indd 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis


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Surgery_Schwartz. 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis majormusclevertical resection increases the incidence of skin necrosis, espe-cially at the confluence of scars in the lower abdomen.Brachioplasty, or arm lift, excises excess skin and subcu-taneous tissue from the arms. It results in improved contour but leaves a visible longitudinal scar on the medial aspect of the arm. Therefore, it is reserved for patients with excessive skin in that region. The patient willing to accept the scar can be happy with the results. Complications include distal seroma and wound separation. Paresthesias in the upper arm and forearm may occur secondary to injury of sensory nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh


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Surgery_Schwartz. nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh and buttock lifts treat loose skin on the thighs and buttocks. A variety of methods have been described, and applica-tion requires proper patient selection in order to obtain the best outcome. The lateral thighs can be lifted simultaneously during abdominoplasty with one scar along the belt line. If the lift is continued on the posterior torso, a buttocks lift can be performed as well. This procedure is referred to as a circumferential lower body lift. Contouring the medial thighs typically requires an inci-sion in the groin crease. Firmly anchoring the deep thigh fascia to Colles’ fascia is essential to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound


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Surgery_Schwartz. to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound separation, skin necrosis, and change in the shape of the genital region (with possible sexual dysfunction).Brunicardi_Ch45_p1967-p2026.indd 202101/03/19 6:32 PM 2022SPECIFIC CONSIDERATIONSPART IIABFigure 45-71. A. Preoperative photo of 35-year-old woman after gastric bypass and massive weight loss. B. Patient 12 months after a fleurde-lis abdominoplasty.Suction LipectomyLiposuction is a technique that involves the removal of adipose tissue through minimal incisions using a hollow suction can-nula system. The key consideration in determining acceptable candidates for this body contouring technique directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin


Surgery_Schwartz

Surgery_Schwartz. directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin tone is a vital part of the preoperative patient evaluation. If there is excessive skin laxity in the body area to be treated, it may worsen after liposuction and contribute to contour irregularities, voids, and abnormal appearance.This technique can be highly effective in the correctly chosen patient as the access port sites provide minimally vis-ible scars and can remove significant amounts of fatty tissue to improve contour. However, it is worth mentioning that liposuc-tion is not considered a weight-loss treatment; rather, it is a tool for addressing unwanted and troublesome adipose depots. Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction


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Surgery_Schwartz. Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction cannula system removes adipose tissue by avulsing fat into the small holes located within the cannula tip. As the cannula is repeatedly passed throughout the adipose planes to remove the fat, one can often visualize and feel the reduction in the fat depot area treated. In general, larger-diameter cannulas remove adi-pose tissue at a faster rate yet carry a higher risk of causing contour irregularities such as grooving and/or uneven removal of fat. Newer liposuction technologies employing ultrasonic or laser probes to heat and emulsify fat via cavitation before suc-tion are gaining increasing application because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat


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Surgery_Schwartz. because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat of the cannula and can cause burn injury to skin and underlying structures.A major advance in the field of liposuction involves appli-cation of tumescent local anesthesia. This method involves the infiltration of very dilute lidocaine and epinephrine (lidocaine 0.05% and epinephrine 1:1,000,000) in large volumes through-out the subcutaneous tissues prior to suction removal of fatty tissue. Tumescent volumes can range from one to three times the anticipated aspirate volume. The dilute lidocaine provides sufficient anesthesia to allow the liposuction to be performed without additional agents in some instances. However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent


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Surgery_Schwartz. However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent anesthesia, the absorption of the dilute lidocaine from the subcutaneous tissue is very slow, with peak plasma concentrations occurring approx-imately 10 hours after the procedure. Therefore, the standard lidocaine dosing limit of 7 mg/kg may be safely exceeded. Cur-rent recommendations suggest a limit of 35 mg/kg of lidocaine with tumescent anesthesia. A very important component of the tumescent anesthetic solution is diluted epinephrine, which has proved to limit blood loss during the procedure.Safety issues are paramount for liposuction because of potential fluid shifts postoperatively and hypothermia. If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and


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Surgery_Schwartz. If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and B. Preoperative photos of a 22-year-old woman with focal adipose deposits on the trunk and extremities. C. Patient 3 months after surgery.Brunicardi_Ch45_p1967-p2026.indd 202301/03/19 6:32 PM 2024SPECIFIC CONSIDERATIONSPART IIperformed in an accredited acute care hospital facility. After the procedure, vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff familiar with perioperative care of the liposuction patient.Autologous Fat GraftingThe concept of reinjecting fat tissue harvested by liposuction has been put into practice for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by


Surgery_Schwartz

Surgery_Schwartz. for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by centrifugation and/or filtering. Ideally, the prepared adipose grafts are then injected into the tissues using specially designed blunt-tipped cannulas that provide for micro-graft injection. Small aliquots of fat grafts are injected with each cannula pass to deposit the grafts within the vascularized tissues of the recipient bed. Autologous fat grafting has gained increased interest and has been applied to various areas of aesthetic and reconstructive surgery. Specific applications include fat grafting to augment areas where fat atrophy is commonplace (aging of the face or hands), to enhance breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital


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Surgery_Schwartz. breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital processes.REFERENCESEntries highlighted in bright blue are key references. 1. Martin, Andrew J. (2005-07-27). “Academy Papyrus to be Exhibited at the Metropolitan Museum of Art” (Press release). The New York Academy of Medicine. Archived from the origi-nal on November 27, 2010. 2. Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plast Surg. 1962;15:242-254. 3. Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104:208-214. 4. Staylor A. Wound care devices: growth amid uncertainty. Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who


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Surgery_Schwartz. Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who studied skin grafting in animals. Baronio’s work represents the first preclinical animal study of a surgical procedure. The logo of the most important professional organization dedicated to plastic surgery research, the Plastic Surgery Research Council, is based on Baronio’s illustration of a sheep with multiple grafted areas of skin on the back. 6. Singh M, Nuutila K, Kruse C, Robson MC, Caterson E, Eriksson E. Challenging the conventional therapy: emerging skin graft techniques for wound healing. Plast Reconstruct Surg. 2015;136(4):524e-530e. 7. Sinha S, Schreiner AJ, Biernaskie J, Nickerson D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical


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Surgery_Schwartz. D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical manage-ment of the burn wound and use of skin substitutes: an expert panel white paper. J Burn Care Res. 2013;34(2):e60-e79. A variety of skin substitutes are available for repairing areas of skin loss from injuries such as deep partial-thickness or full-thickness burns. This article provides a nice summary of con-temporary options. 9. Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013;70(1):23-29. 10. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann


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Surgery_Schwartz. including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann Plast Surg. 1991;27(6):509-516; discussion 517-518. 12. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plastic Surg. 1973;26(3):202-213. 13. Rajabi A, Dolovich AT, Johnston JD. From the rhombic transpo-sition flap toward Z-plasty: an optimized design using the finite element method. J Biomech. 2015;48(13):3672-3678. 14. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg. 1971;24(2):174-183. 16. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evo-lution, classification, and applications. Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI,


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Surgery_Schwartz. Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-141. This is the classic article studying blood supply to the skin that introduced the angiosome concept and transformed our under-standing of the anatomic basis of surgical flap design. The blood supply was shown to be a continuous three-dimensional network of vessels in all tissue layers. The anatomical territory of a source artery corresponded in both the skin and deep tissues and gave rise to the angiosome concept. 19. Buchanan PJ, Kung TA, Cederna PS. Evidence-based medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale


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Surgery_Schwartz. medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale for vari-ous wound care methods, including dressings, negative pressure wound therapy, skin and dermal substitutes, and tissue expan-sion. This is basic knowledge that is important for all surgeons to understand. 20. Whitaker LA, Pashayan H, Reichman J. A proposed new classification of craniofacial anomalies. Cleft Palate J. 1981;18(3):161-176. 21. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip and nasal deformity. Plast Reconstr Surg. 2013;132(6): 1040e-1053e. 22. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles &


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Surgery_Schwartz. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016: 453-478. 24. van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg. 2008; 121(1 suppl):1-14. 25. Garfinkle JS, Grayson BH. Nasoalveolar molding and columella elongation in preparation for the primary repair of unilateral and bilateral cleft lip and palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadel-phia: Elsevier; 2013:1223-1251. 26. Kirschner REA, Losee JE. Lip adhesion. In: Losee J, Kirschner RE, eds. Comprehensive Cleft Care. Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial,


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Surgery_Schwartz. Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadelphia: Elsevier; 2013:568-583.Brunicardi_Ch45_p1967-p2026.indd 202401/03/19 6:32 PM 2025PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45 28. Moe KS, Murr AH, Wester ST. Orbital Fractures. Facial Plast Surg Clin North Am. 2018 May;26(2):237-251. doi: 10.1016/j.fsc.2017.12.007. Review. PubMed PMID: 29636153. 29. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 30. Patel PK, Kawamoto HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical


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Surgery_Schwartz. HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg. 1976;4(2):69-92. 32. Monasterio FO, Taylor JA. Major craniofacial clefts: case series and treatment philosophy. Plast Reconstr Surg. 2008;122(2):534-543. 33. Forrest CR, Nguyen PD, Smith DM. Craniosynostosis. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pedi-atric Plastic Surgery. Boca Raton: CRC Press; 2016:595-647. 34. Fearon JA. Evidence-based medicine: craniosynostosis. Plast Reconstr Surg. 2014;133(5):1261-1275. 35. Persing JA. MOC-PS(SM) CME article: management consider-ations in the treatment of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti


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Surgery_Schwartz. of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morphological resto-ration of hemifacial progressive atrophy. Plast Reconstr Surg. 2005;116(3):699-711. 38. Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunning-ham ML. Robin sequence: from diagnosis to development of an effective management plan. Pediatrics. 2011;127(5):936-948. 39. Kirschner RE, Low DW, Randall P, et al. Surgical airway man-agement in Pierre Robin sequence: is there a role for tongue-lip adhesion? Cleft Palate Craniofac J. 2003;40(1):13-18. 40. Overdiek A, Feifel H, Schaper J, Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous


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Surgery_Schwartz. Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous dyspla-sia. Oral Maxillofac Surg Clin North Am. 2012;24(3):427-441. 42. Mulliken JB, Glowacki J. Hemangiomas and vascular malfor-mations in infants and children: a classification based on endo-thelial characteristics. Plast Reconstr Surg. 1982;69(3):412-422. 43. Greene AK, Phillips JH. Vascular anomalies. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:199-230. 44. Biswas A, Pan X, Meyer M, et al. Urinary excretion of microRNA-126 is a biomarker for hemangioma proliferation. Plast Reconstr Surg. 2017;139(6):1277e-1284e. 45. Iacobas I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5):


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Surgery_Schwartz. I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5): 795-801.e1-e7. 46. Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction. Breast. 2005 Apr;14(2):118-30. Review. PubMed PMID: 15767181. 47. Nicholas Zdenkowski, Butow P, Tesson S, Boyle F. A system-atic review of decision aids for patients making a decision about treatment for early breast cancer. Breast. 2016 Apr;26:31-45. doi: 10.1016/j.breast.2015.12.007. Epub 2016 Jan 8. Review. PubMed PMID: 27017240. 48. Cho BC, McCready DR. Oncologic principles in breast recon-struction. Clin Plast Surg. 2007 Jan;34(1):1-13; abstract v. Review. PubMed PMID: 17307067. 49. Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr


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Surgery_Schwartz. Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr Surg. 2009;124(1 suppl):1e-13e. 51. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: review and clinical appli-cations. Plast Reconstr Surg. 2014;133(2):367-376. 52. Millard DR. Principlization of Plastic Surgery. 1st ed. Boston/Toronto: Little, Brown; 1986. 53. Corcoran J, Bauer BS. Cutaneous lesions. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:453-478. 54. Bosse MJ et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and


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Surgery_Schwartz. 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38(8):879-889. 57. Cho EH, Shammas RL, Carney MJ, et al. Muscle versus fascio-cutaneous free flaps in lower extremity traumatic reconstruc-tion: a multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191-199. 58. Yazar S, Lin CH, Wei FC. One-stage reconstruction of compos-ite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114(6):1457-1466. 59. Gurney JK(1), Stanley J(2), York S(3), Rosenbaum D(4), Sar-fati D(2). Risk of lower limb amputation in a national preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in


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Surgery_Schwartz. preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in Deciding on Limb Salvage versus Amputation in Patients With Diabetes? Plast Reconstr Surg. 2016 Sep;138(3 Suppl):188S-95S. doi: 10.1097/PRS.0000000000002713. Review. PubMed PMID: 27556759. 61. Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: an update. Plast Reconstr Surg. 2017;140:60S-68S. Radiation therapy has an adverse effect on all forms of breast reconstruction. The need for radiation therapy affects the opti-mal timing and technique for breast reconstructive surgery. It is helpful for all surgeons caring for breast cancer patients to have an understanding of the issues involved, and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic


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Surgery_Schwartz. and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic defects. Plast Reconstr Surg. 2017;140(4):601e-612e. General surgeons often encounter problems in the perineum. This article offers an excellent summary of how to manage surgical problems in this region. It provides a review of anat-omy, the types of problems encountered, and appropriate local, regional, or free-flap options based on the location of the defect and donor-site characteristics. 63. Cushing CA, Phillips LG. Evidence-based medicine: pres-sure sores. Plast Reconstr Surg. 2013;132(6):1720-1732. Pressure sores are a common problem affecting surgical patients of all types, and it is important for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment


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Surgery_Schwartz. for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment options. Most impor-tantly, it reviews steps for the prevention of pressure sores.64. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. 65. Centers for Disease Control and Prevention. 2017 National Diabetes Statistics Report, 2017. Available at: https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed January 20, 2019.Brunicardi_Ch45_p1967-p2026.indd 202501/03/19 6:32 PM 2026SPECIFIC CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist


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Surgery_Schwartz. CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28(suppl 1):179-217. 68. Johnson SK, Podratz KE, Dipboye RL, Gibbons E. Physi-cal attractiveness biases in ratings of employment suitability: tracking down the “beauty is beastly” effect. J Soc Psychol. 2010;150(3):301-318. 69. Jacono A, Chastant RP, Dibelius G. Association of patient self-esteem with perceived outcome after face-lift surgery. JAMA Facial Plast Surg. 2016;18(1):42-46. 70. Schwitzer JA, Sher SR, Fan KL, Scott AM, Gamble L, Baker SB. Assessing patient-reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg.