• Surgery of the Hand
    • 1

      Upper Extremity Compartment Syndrome

      By Jacob M Kirsch, MD; Simon Lee, MD; Jeffrey N Lawton, MD
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      Upper Extremity Compartment Syndrome

      • JACOB M KIRSCH, MDDepartment of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
      • SIMON LEE, MDDepartment of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
      • JEFFREY N LAWTON, MDDepartment of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI

      Acute compartment syndrome (ACS) of the upper extremity is a surgical emergency resulting from decreased perfusion pressures and tissue hypoxia. Variable clinical presentation and physical examination findings produce unique challenges for physicians. Concomitant injuries can often further complicate the clinical picture. Prompt evaluation and diagnosis are essential to maximize functional outcomes and minimize potentially devastating sequelae. Emergent decompression of the involved fascial compartments is required to reestablish the vascular pressure gradient necessary for adequate tissue perfusion and oxygenation. An understanding of the epidemiology, pathophysiology, clinical diagnosis, pertinent anatomy, and surgical management of ACS is essential for the upper extremity surgeon.   

      This review contains 15 figures, 3 tables and 74 references

       Key words: acute compartment syndrome, arm, compartments, fasciotomy, forearm, fracture, hand, surgical decompression, trauma, upper extremity

       

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    • 2

      Reconstruction of the Thumb After Traumatic Tissue Loss

      By James E Clune, MD; Neil F Jones, MD
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      Reconstruction of the Thumb After Traumatic Tissue Loss

      • JAMES E CLUNE, MDAssistant Professor, Section of Plastic Surgery, Yale School of Medicine, New Haven, CT
      • NEIL F JONES, MDProfessor and Chief of Hand Surgery, Department of Orthopedic Surgery, University of California, Irvine, Orange, CA

      The distinctive prehensile functions of the human hand are orchestrated by the thumb. Without a thumb, the hand lacks critical movements allowing for pinch, grasp, and fine manipulation. Based on the patient’s individual needs, occupation, and desires, thumb reconstruction should be offered to every patient with a traumatic amputation. Position, stability, mobility, and sensation command attention when reconstructing the absent thumb. We present the spectrum of various techniques available for reconstructing a useful thumb.


      This review contains 10 figures, 3 tables and 51 references. 

      Key words: Thumb; reconstruction, amputation, pollicization, toe transfer, metacarpal lengthening, webspace deepening

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    • 3

      Common Congenital Hand Differences

      By Francisco Soldado, MD, PhD; Scott Kozin, MD
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      Common Congenital Hand Differences

      • FRANCISCO SOLDADO, MD, PHDChief of Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
      • SCOTT KOZIN, MDChief of Staff, Shriners Hospital for Children, Philadelphia, PA

      Congenital differences of the hand are common in a pediatric hand surgery practice. The child’s global health and genetic counseling should be addressed before focusing on the upper limb disorder. Appropriate referral is necessary to facilitate education about the congenital difference and its effect on subsequent generations. The physician must be comfortable and have a sound understanding of the diagnosis and treatment algorithm. Reoperation rates are high for even the most common congenital hand defects treated by experienced surgeons. Syndactyly, polydactyly, thumb hypoplasia, and symbrachydactyly are particularly commonplace and are discussed in this review. The main aim when treating these disorders is improving hand function; however, aesthetics must also be considered when planning surgery.

      This review contains 36 figures, 3 tables and 50 references

       Key words: congenital hand differences, pediatric hand, symbrachydactyly, syndactyly, thumb duplication, thumb hypoplasia

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    • 4

      Vascular Disorders of the Hand

      By Matthew Treiser, MD; Christian E Sampson, MD
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      Vascular Disorders of the Hand

      • MATTHEW TREISER, MD
      • CHRISTIAN E SAMPSON, MD

      Vascular disorders of the hand and upper extremity encompass a wide range of conditions that can cause peripheral ischemia. These can be purely mechanical in nature, secondary to trauma. They can also be the culmination of multiple systemic diseases, including peripheral arterial disease, end-stage renal disease, and a variety of connective tissue disorders. Key to the successful management of ischemia of the hand and upper extremity is a clear diagnosis. It is only then that the appropriate treatment algorithm can be employed. This review provides an overview of the relevant anatomy and key aspects of the hand and upper extremity physical examination as they pertain to identifying vascular pathology, as well as current state of the art diagnostic modalities. Finally, we discuss some of the more common conditions that affect the hand and upper extremity leading to upper extremity ischemia. The reader should come away with a clear understanding of hand and upper extremity vascular anatomy, how to perform a focused physical examination to identify relevant pathology, and which diagnostic modalities will be most appropriate to make a diagnosis.

      This review contains 9 figures and 52 references.

      Key words: Allen test, aneurysm, arteriography, botulinum toxin, Buerger disease, CT angiography, hypothenar hammer syndrome, ischemia, magnetic resonance angiography, Raynaud phenomenon, sympathectomy vascular anatomy, vascular pathology

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    • 5

      Tenosynovitis Disorders of the Hand and Wrist

      By Michael Aversano, MD; Nader Paksima, MD
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      Tenosynovitis Disorders of the Hand and Wrist

      • MICHAEL AVERSANO, MD
      • NADER PAKSIMA, MD

      The diagnosis and treatment of patients with tenosynovitis disorders of the hand and wrist are complex and must take into account the heterogeneity and natural history of each condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This review serves to summarize some of the recent publications in the field of hand surgery that have made important contributions to our understanding and care of the patient with tenosynovitis. Updates in the field of hand surgery are constant, and the current level of evidence for the effectiveness of specific treatment modalities in patients with tenosynovitis of the hand and wrist was reviewed. We searched the PubMed database and identified clinical trials, meta-analyses, reviews, and guidelines contributing important findings and knowledge to extensor and flexor compartment tenosynovitis of the hand and wrist. Our understanding of tenosynovitis disorders of the hand and wrist continues to grow and expand. Nevertheless, a paucity of randomized controlled trials and higher evidence research may contribute to the variability in current practices among providers. By elucidating these gaps, we can more purposefully delegate our time and resources into targeted areas of research and treatment.

      This review contains 11 figures, 1 table and 86 references.

      Key words: corticosteroid injection, de Quervain disease, hand/wrist pain, tendonitis, tenosynovitis, trigger finger

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    • 6

      Flexor Tendon Injuries

      By Chao Long, AB; Lisa C Moody, MD; Paige M Fox, MD, PhD; James Chang, MD
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      Flexor Tendon Injuries

      • CHAO LONG, ABMedical Student, Division of Plastic & Reconstructive Surgery, Stanford Health Care, Stanford, CA
      • LISA C MOODY, MDClinical Assistant Professor, Division of Plastic & Reconstructive Surgery, Stanford Health Care, Stanford, CA
      • PAIGE M FOX, MD, PHDAssistant Professor, Division of Plastic & Reconstructive Surgery, Stanford Health Care, Stanford, CA
      • JAMES CHANG, MDChief, Division of Plastic & Reconstructive Surgery, Stanford Health Care, Stanford, CA

      Flexor tendon injuries are common hand injuries that can significantly affect hand function. Treatment of these injuries requires a thorough understanding of the intricate anatomy and biomechanics of flexor tendons. The goals of reconstruction include restoration of tendon continuity, preservation and reconstruction of the pulley system, maximizing tendon gliding, and minimizing adhesion formation. Surgical treatment, in conjunction with postoperative hand therapy, provides enhanced function. This review provides the surgeon with the relevant anatomy, pearls of clinical evaluation, necessary investigative studies, management algorithms, surgical techniques, rehabilitation protocols, and approaches to common complications. It ends with a discussion of basic and translational research currently being undertaken to address the challenges posed by flexor tendon injuries and how this research can potentially advance patient care.

       

      This review contains 16 figures, 5 tables and 55 references

      Key words: flexor tendon, flexor tendon injuries, flexor tendon reconstruction, flexor tendon repair, hand, hand surgery, injury, surgical technique, tendons

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    • 7

      Wrist Fractures and Dislocations

      By Angelo B Lipira, MD; Rahul K Kasukurthi, MD; Jerry I Huang, MD
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      Wrist Fractures and Dislocations

      • ANGELO B LIPIRA, MD
      • RAHUL K KASUKURTHI, MD
      • JERRY I HUANG, MD

      Wrist injuries are common and encompass a wide variety of pathologies. This review discusses key concepts related to the evaluation and management of wrist injuries, including bony and ligamentous injuries of the carpus, fractures of the distal radius and ulna, and associated conditions. Pertinent anatomy and biomechanical principles are briefly reviewed, followed by more detailed discussions of evaluation and management of specific injury types based on best available evidence. A diagnostic approach including the history, physical examination, and imaging is reviewed for each injury type. Common surgical approaches, fixation methods, and reconstructive techniques are then described within each section. Numerous illustrations, radiographs, and cadaveric photographs are included.

      This review contains 32 figures, 2 tables and 76 references

      Key words: carpal, carpus, distal radius, fracture, ligament, lunotriquetral, scaphoid, scapholunate, wrist

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    • 8

      Microsurgical Reconstruction of the Upper Extremity

      By Nikolas H Kazmers, MD, MSE; Stephanie Thibaudeau, MD; Zvi Steinberger, MD; L. Scott Levin, MD, FACS
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      Microsurgical Reconstruction of the Upper Extremity

      • NIKOLAS H KAZMERS, MD, MSE
      • STEPHANIE THIBAUDEAU, MD
      • ZVI STEINBERGER, MD
      • L. SCOTT LEVIN, MD, FACS

      The advent of free tissue transfer has revolutionized upper extremity reconstruction in the setting of trauma, infection, and oncologic resection. Current microsurgical techniques allow for soft tissue coverage, osseous reconstruction, and free functioning muscle transfer. This review highlights perioperative planning considerations in terms of the timing of reconstruction and flap choice, as well as indications and contraindications, for upper extremity microsurgical reconstruction. Many commonly used fasciocutaneous, muscle, and osseous free flap options are reviewed, with specific emphasis on surgically relevant anatomy, flap variations, and pearls and pitfalls. Many of these free flap options are illustrated using case examples.

      This review contains 15 figures, 3 tables and 109 references.

      Key words: bone defect, elbow, free flap, hand, microsurgery, reconstruction, upper extremity, wrist

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    • 9

      Hand Fractures

      By Issei Komatsu, MD; Thomas B Hughes Jr, MD
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      Hand Fractures

      • ISSEI KOMATSU, MD
      • THOMAS B HUGHES JR, MD

      Fractures of the metacarpals and phalanges are common. Clinical evaluation, including eliciting the mechanism of injury, physical examination observing skin integrity, neurovascular status, rotational and angular deformity, and arc of motion and stability in each joint, and review of dedicated radiographs are needed to guide successful fracture management. Most of these fractures can be successfully managed by nonoperative techniques. However, operative fixation is indicated in certain fractures. In this review, we discuss the most representative hand fractures and their management. We also highlight various surgical treatment options, with recent clinical research findings for each fracture pattern.


      This review contains 10 figures, 2 tables and 54 references

      Key words: metacarpal fractures, phalangeal fractures, thumb fractures

       

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    • 10

      Hand Infections

      By Scott D Lifchez, MD, FACS; Colton McNichols, MD
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      Hand Infections

      • SCOTT D LIFCHEZ, MD, FACSAssociate Professor of Plastic Surgery and Orthopedic Surgery Johns Hopkins University School of Medicine Program Director Johns Hopkins/University of Maryland Plastic Surgery Residency Program
      • COLTON MCNICHOLS, MDResident Johns Hopkins /University of Maryland Plastic Surgery Residency Program

      Hand infections are a common concern in the emergency, outpatient, and inpatient setting. It is important to accurately diagnose and treat these infections to minimize the risk of spread or functional deficit that could be permanent if not addressed in a timely manner. In this chapter, we aim to cover the epidemiology and etiology of hand infections along with how they tend to present in the clinical setting. This chapter is written so that each encounter can be analyzed in a logical, step-wise fashion from formulating a differential diagnosis to treatment. Upon evaluation, it is important to perform a thorough clinical examination in addition to knowing which imaging modalities can help elucidate the pathology when the initial presentation is unclear. These and other diagnostic studies are covered so that the differential diagnosis can be narrowed down. Each of the possible scenarios is clarified further to help confirm the most likely diagnosis. Finally, we touch on each treatment (whether surgical or medical) recommended for the suspected disease process. Overall, it is important to discern whether the patient will need a small procedure, surgery, or medication alone so that the appropriate management is performed and optimal healing is possible.

      This review contains 25 Figures, 10 Tables and 26 references

      Key Words: acute infection, chronic infection, paronychia, felon, flexor tenosynovitis, septic joint, hand infection, hand surgery

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  • Principles of Plastic Surgery
    • 1

      Biology of Aging

      By Deepak Bharadia, MD; Raquel Minasian, MD; Indranil Sinha, MD
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      Biology of Aging

      • DEEPAK BHARADIA, MDDivision of Plastic Surgery, University of California, San Francisco
      • RAQUEL MINASIAN, MDDivision of Plastic Surgery, Keck School of Medicine, University of Southern California
      • INDRANIL SINHA, MDDivision of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School

      With aging, there are multiple internal and external factors that are associated with age-related changes in skin and soft tissue.  As Plastic Surgeons, we very commonly evaluate and treat elderly patients, often offering ‘anti-aging’ treatments.  An understanding of the science behind aging as well as common patterns of change seen in soft tissue may allow us to refine our treatments.  This review provides an overview of mechanisms underlying aging, as well common clinical scenarios with aging regarding anatomic sites commonly treated by Plastic Surgeons including the face, breast, and abdomen.  Separately, we discuss aging associated changes to specific tissue types, including skin, fat, muscle, and bone.  Knowledge of factors related to aging and concepts related to safe interventions to reverse or mitigate age-related changes and integral to our ability to care for the elderly population.

       

      This review contains 9 figures, 3 tables and 69 references

      Key Words : Cellular senescence, mitochondrial theory, free radical theory, inflammation, protein damage hypothesis, glycation hypothesis, atrophy, lipotoxicity, rhytids, involution

       

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    • 2

      A Comprehensive Review of Wound Healing

      By Raman Mehrzad, MD, MHL, Postdoctoral Research Fellow; Paul Y Liu, MD, FACS, Professor of Surgery
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      A Comprehensive Review of Wound Healing

      • RAMAN MEHRZAD, MD, MHL, POSTDOCTORAL RESEARCH FELLOWDepartment of Plastic and Reconstructive Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI
      • PAUL Y LIU, MD, FACS, PROFESSOR OF SURGERYChair, Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI

      Unhealed wounds are a largely hidden epidemic, affecting 6.5 million Americans and costing about $25 billion a year, with numerous patients affected. Unhealed wounds result in lower quality of life and limit many all-day activities for patients. Despite this large socioeconomic burden, there have been only a few meaningful advances in the science of wound care. Wounds represent a cross section of many medical disciplines—diabetes, trauma, hypertension, vascular insufficiency, and rheumatologic diseases—and a multidisciplinary approach is typically needed. In this review, we provide an overview of wound healing, its pathophysiology, different types of wounds, and the current state of therapeutic art.

       

      Key words: chronic wounds, infection, inflammation, mathematical modeling, ulcers, wounds

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  • Trunk and Perineal Reconstruction
    • 1

      Male-to-female Gender-confirming Surgery

      By Shane D Morrison, MD, MS; Stelios C Wilson, MD; Marcelina G Perez, Medical Student; Thomas Satterwhite, MD
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      Male-to-female Gender-confirming Surgery

      • SHANE D MORRISON, MD, MSPlastic Surgery Resident, Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
      • STELIOS C WILSON, MDPlastic Surgery Resident, Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, NY
      • MARCELINA G PEREZ, MEDICAL STUDENTStanford University School of Medicine, Stanford, CA
      • THOMAS SATTERWHITE, MDAttending Surgeon, Brownstein and Crane Surgical Services, San Francisco, CA

      Advances in male-to-female gender-confirming surgery enable acquisition of female secondary sexual characteristics for gender dysphoric patients desiring surgical transition. It is imperative for medical professionals caring for transgender patients to be informed of the current standards of care and the available surgical options. This review discusses male-to-female chest and genital reconstructive surgical approaches.

      This review contains 27 figures, 5 tables and 52 references

       Key words: augmentation mammoplasty, gender-confirming surgery, genital reconstruction, male to female, transgender, vaginoplasty 

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    • 2

      Abdominal Wall Reconstruction

      By Gregory A. Dumanian, MD, FACS
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      Abdominal Wall Reconstruction

      • GREGORY A. DUMANIAN, MD, FACSDivision of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL

      The closure of the abdominal wall defects is a fascinating field within surgery. The combined strength of sutures and scar after simple approximation of tissues in many cases does not suffice to contain the abdominal viscera and an incisional hernia results. Surgical failure can be seen immediately in the dramatic form of a dehiscence or can emerge slowly over time with a change in the abdominal shape and contour. This chapter delves into the theory and practicum of how a surgeon can approximate two halves of an abdominal wall together to resist the inherent tensile forces that exist and create a durable closure.

      This review contains 19 figures and 35 references

      Key Words: bioprosthetic, bridging, component release, force distribution, foreign body reaction, gap formation, hernia, laparotomy, mesh, perforator preservation, rectus diastasis, suture pull-through, TAR release

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  • Head and Neck Reconstruction
    • 1

      Reconstructive Approaches to Nasal Defects

      By Ravi K Garg, MD; Michael L Bentz, MD
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      Reconstructive Approaches to Nasal Defects

      • RAVI K GARG, MD
      • MICHAEL L BENTZ, MD

      Nasal reconstruction is commonly performed for treatment of defects arising from excision of nonmelanoma skin cancers, although other tumors, trauma, or infection may also result in significant nasal deformities necessitating corrective surgery. Patients being evaluated for nasal reconstruction should have a functional assessment of airflow through both the internal and external nasal valves to determine the need for reconstructive maneuvers that will maintain or improve the nasal airway. Aesthetic considerations relate to which nasal subunits are missing and how local, regional, and sometimes free tissue transfer can be used to optimize the final appearance of the nose. Reconstruction must incorporate a plan for reestablishing nasal lining, support, and cover depending on which elements are missing. Postoperative considerations include the need for nasal splints and interventions to optimize nasal scarring and contour such as scar massage, steroid injection, and laser treatments. Patients who are not good candidates for autologous nasal reconstruction may be considered for prosthetic reconstruction.

      This review contains 13 figures and 67 references

      Key words: Nasal reconstruction, Nasal airway, Mohs surgery, Skin cancer, Nasal aesthetic subunits, Facial flaps, Skin graft, Forehead flap, Nasal cover, Nasal lining, Nasal support, Prosthetic rehabilitation

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    • 2

      Hypopharyngeal, Esophageal, and Neck Reconstruction

      By Steven B Chinn, MD MPH; Peirong Yu, MD
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      Hypopharyngeal, Esophageal, and Neck Reconstruction

      • STEVEN B CHINN, MD MPHAssistant Professor, Departmens of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
      • PEIRONG YU, MDProfessor, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX

      Organ preservation protocols with radiotherapy have become the primary treatment for stage I to III laryngeal and hypopharyngeal carcinoma. Many pharyngoesophageal defects are the result of salvage laryngopharyngectomy following radiation failure, making reconstruction more challenging. Given the detrimental effects of radiation on wound healing, reconstruction bathed in saliva, and the frozen neck with poor recipient vessels, pharyngoesophageal reconstruction requires great attention to detail to avoid catastrophic complications. In this review, we detail the commonly used flaps for pharyngoesophageal reconstruction, including the radial forearm flap, anterolateral thigh flap, and jejunal flap. In recent years, the anterolateral thigh flap has become the optimal flap for this type of reconstruction due to its minimal donor-site morbidity and excellent functional outcomes. Use of a two-skin island anterolateral flap allows for pharyngoesophageal reconstruction with simultaneous neck resurfacing. The profundus artery perforator flap can be a good alternative to the anterolateral thigh flap, whereas the ulnar artery perforator flap may be a good alternative to the radial forearm flap in certain cases. We discuss recipient vessel selection and conclude by outlining important postoperative considerations.

      This review contains 23 figures, 3 tables and 39 references

      Key words: anterolateral thigh flap, anteromedial thigh flap, frozen neck, gastro-omental flap, hypopharynx, laryngeal cancer, perforator flaps, pharyngocutaneous fistula, pharyngoesophageal reconstruction, profundus artery perforator flap, radial forearm flap, tracheoesophageal puncture, transverse cervical vessels, ulnar artery perforator flap

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    • 3

      Head and Neck Melanoma: an Overview

      By Samuel Kim, MD; Deepak Narayan, MD
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      Head and Neck Melanoma: an Overview

      • SAMUEL KIM, MDResearch Fellow, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT
      • DEEPAK NARAYAN, MDProfessor of Surgery (Plastic), Chief, Plastic Surgery, West Haven, VA; Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT

      Melanoma is one of the most common cancers in the United States, and its incidence has been steadily rising. Despite the increasing incidence, 5-year survival rates are over 90%, in large part due to early detection and advances in treatment. Head and neck melanomas encompass up to a quarter of all melanomas despite the head and neck making up only 9% of total body surface area. Although under the overall classification of melanoma, head and neck melanomas are distinct in many ways that influence their management. In this review, we provide current concepts in the risk factors, genetics, classifications, diagnosis, surgical and nonsurgical management, and future therapies of head and neck melanoma.


      This review contains 26 figures, 9 tables and 123 references

      Key words: Checkpoint inhibition therapy; Head and neck melanoma; Imiquimod; NF1; Oncogene-targeted therapy; Parotid-sparing sentinel lymph node biopsy; RAC1; Selective neck dissection

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    • 4

      Facial Transplantation

      By Mario A Aycart, MD; Bohdan Pomahac, MD
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      Facial Transplantation

      • MARIO A AYCART, MDResident in Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, United States
      • BOHDAN POMAHAC, MDAssociate Professor of Surgery, Harvard Medical School, Director of Plastic Surgery, Transplantation and Burn Center, Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, United States

      Although significant advances in craniofacial and microsurgical reconstructive techniques have allowed for the reliable reconstruction of complex head and neck defects, there are limitations to conventional therapy. In the past decade, the medical community has witnessed the growth and evolution of facial transplantation in becoming a clinical reality for the most severely disfigured individuals. Despite recent advances and promising short-term results, the risk-benefit trade-off is still evolving as more experience is gained. This chapter provides a comprehensive overview of indications, recipient evaluation, and immunosuppression. The latest outcomes’ data including functional outcomes, costs, quality of life, complications, and deaths from the emerging field of facial transplantation are also reviewed.

      This review contains 11 figures, 5 tables and 92 references

      Key Words: Facial Transplantation, Vascularized composite allotransplantation, Composite tissue transplantation, Reconstruction Microsurgery, Craniofacial Surgery, Transplant Surgery, Immunosuppression, Functional Outcomes

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  • Congential Anomolies of the Head and Neck
    • 1

      Vascular Anomalies

      By Arin K Greene, MD, MMSc; Javier A Couto, MD
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      Vascular Anomalies

      • ARIN K GREENE, MD, MMSC
      • JAVIER A COUTO, MD

      Vascular anomalies are common pediatric lesions affecting approximately 5% of the population. Lesions are broadly classified into tumors and malformations. The most common tumors are infantile hemangioma, congenital hemangioma, pyogenic granuloma, and kaposiform hemangioendothelioma. The major malformations are capillary, lymphatic, venous, and arteriovenous. Almost all lesions can be diagnosed by the history and physical examination. Ultrasonography is usually the first-line imaging study to confirm a diagnosis. Management of vascular anomalies is based on the type of lesion. Treatments include resection, systemic pharmacotherapy, intralesional drugs, laser, sclerotherapy, and/or embolization. Most patients are best managed in an interdisciplinary vascular anomalies center.

      This review contains 9 figures, 2 tables and 29 references

      Key words: arteriovenous, capillary, congenital, hemangioma, kaposiform, lymphatic, malformation, pyogenic, vascular, venous

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    • 2

      Distraction Osteogenesis in Plastic Surgery

      By Elizabeth G Zellner, MD; Derek M Steinbacher, DMD, MD, FACS
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      Distraction Osteogenesis in Plastic Surgery

      • ELIZABETH G ZELLNER, MDAssistant Professor of Surgery, Division of Plastic Surgery, New York Medical College, Valhalla, NY, United States,
      • DEREK M STEINBACHER, DMD, MD, FACSAssociate Professor of Surgery, Section of Plastic Surgery, Chief of Oral and Maxillofacial Surgery, Director of Craniofacial Surgery, Yale University School of Medicine, New Haven, CT, United States

      Distraction osteogenesis (DO), the gradual controlled movement of osteotomized bone to create native bone de novo, is a powerful tool in the reconstructive surgeon’s armamentarium. Originally developed by Ilizarov in the early twentieth century in Russia for use on the long bones of the leg, Snyder, McCarth, and other craniofacial pioneers popularized the technique in the well-vascularized bones of the facial skeleton. DO involves making a planned osteotomy perpendicular to the desired vector of skeletal growth and then applying incremental traction across this opening to encourage the growth of new osteogenic matrix. With adequate stabilization, this bony regenerate becomes ossified and remodels into a new bone. Although the original studies used distraction n the mandible, applications can now be found in the maxilla, midface, and cranial vault. Established bony flaps or grafts can also be distracted to allow for more creative solutions. In the past few decades, device technology has rapidly advanced with new simplified external devices and smaller buried internal distraction devices. In the absence of adequate bone stock, distraction offers a unique opportunity to create new bone and shape overlying the soft tissue.

      This review contains 7 figures, 2 tables and 69 references

      Keywords: Distraction osteogeneis, mandible, craniofacial, craniosynostosis, micrognathia, Robin Sequence, glossoptosis, regenerate, consolidation, distraction device.

       
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    • 3

      Cleft Palate

      By Oksana A Jackson, MD; Alison E Kaye, MD; David W Low, MD
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      Cleft Palate

      • OKSANA A JACKSON, MDAssociate Professor, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
      • ALISON E KAYE, MDAssistant Professor, Division of Plastic Surgery, Children’s Mercy Hospital, Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
      • DAVID W LOW, MDProfessor, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

      A cleft of the palate represents one of the most common congenital anomalies of the craniofacial region. Palatal clefting can occur in combination with a cleft of the lip and alveolus or as an isolated finding and can vary significantly in severity. The intact palate is a structure that separates the oral and nasal cavities, and the function of the palate is to close off the nasal cavity during deglutition and to regulate the flow of air between the nose and mouth during speech production. An unrepaired cleft palate can thus result in nasal regurgitation of food and liquid, early feeding difficulties, and impaired speech development. The goals of surgical repair are to restore palatal integrity by closing the cleft defect and repairing the musculature to allow for normal function during speech. The secondary goal of cleft palate repair is to minimize deleterious effects on growth of the palate and face, which can be impacted by standard surgical interventions. This review describes two of the most commonly performed cleft palate repair techniques in use today, as well as highlighting special anatomic considerations, summarizing perioperative care, and reviewing postoperative complications and their management.

      This review contains 11 figures, 2 videos, 3 tables and 63 references

      Key words: cleft, cleft team, Furlow, orofacial, oronasal fistula, palatoplasty, speech, submucous cleft, velopharyngeal insufficiency

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  • Cosmetic Surgery
    • 1

      Minimally Invasive Approaches to Forehead Rejuvenation

      By Dhivya R Srinivasa, MD; Paul S Cederna, MD
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      Minimally Invasive Approaches to Forehead Rejuvenation

      • DHIVYA R SRINIVASA, MDResident, University of Michigan Health System Department of Surgery, Section of Plastic Surgery, Ann Arbor, MI
      • PAUL S CEDERNA, MDRobert Oneal Collegiate Professor of Plastic Surgery, Section Head, Plastic Surgery; Professor, Department of Biomedical Engineering University of Michigan Health System, Ann Arbor, MI

      Brow position is an established measure of both gender and youth. Patient goals can range from facial feminization to restoration of a more youthful form. Since its introduction in 1994, the endoscopic brow lift has become increasingly popular for elevation and stabilization of the brow, although numerous aesthetic surgeons still question its efficacy. The endoscopic brow lift demands a detailed understanding of specialized endoscopic instruments and regional anatomy. The dissection is tactile at times, but key portions require either direct or endoscopic visualization. Fixation options are numerous, each with their specific risks and benefits. Most importantly, well-planned surgical technique is key in avoiding the stigmata of brow surgery, such as a raised hairline, overcorrection with a surprised facade, and incisional alopecia. In this chapter, we review pertinent anatomy and an algorithm for brow ptosis evaluation. We discuss the specialized instruments necessary to perform this procedure and surgical techniques to maximize outcome while minimizing complications. In preparing patients for this procedure, we review the complication profile and key points of preoperative discussion. A well-done endoscopic brow lift can offer patients a sustainable, stable result with minimal surgical scars and should be included in the armamentarium of an aesthetic surgeon.

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    • 2

      Upper Blepharoplasty

      By Tiffany N Ballard, MD; Robert H Gilman, MD, DMD
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      Upper Blepharoplasty

      • TIFFANY N BALLARD, MDResident, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
      • ROBERT H GILMAN, MD, DMDAssistant Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI

      This article is intended to provide the practitioner with the basics of upper lid blepharoplasty. We discuss the normal anatomy of the upper eyelid and its relationship to facial aesthetics. We also discuss the evaluation for upper eyelid surgery and surgical planning. We present the author’s preferred operative technique and talk about some variations in approach. We also discuss potential postoperative complications and patient outcomes. The illustrations and photographs are supplemented with video materials.

       

      This review contains 6 figures, 12 videos and 25 references

      Key Words: blepharochalasis, green forceps, lacrimal duct, lacrimal gland, levator palpebrae, levator  aponeurosis, Müller’s muscle, orbital fat, orbicularis oculi, orbital septum, preseptal, postseptal, ROOF, tarsal fold, tarsal plate, skin-pinch technique

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  • Wound Healing
    • 1

      Dermatologic Wounds

      By Luis J Borda, MD; Penelope J Kallis, BS; Jose A Jaller, MD; Robert S Kirsner, MD, PhD
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      Dermatologic Wounds

      • LUIS J BORDA, MDWound Research Fellow Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States,
      • PENELOPE J KALLIS, BSWound Research Fellow, Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States,
      • JOSE A JALLER, MDWound Research Fellow, Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States,
      • ROBERT S KIRSNER, MD, PHDChairman and Harvey Blank Professor, Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States

      A wound is characterized as a disruption on the epidermis continuity of either skin or mucosa as a result of physical damage or an underlying disease. Dermatologic wounds may be produced by infection, prolonged pressure, malignancy, neuropathy, ischemia, venous insufficiency, inflammatory conditions, drugs, and external causes. The most common etiologies of chronic wounds are venous leg ulcers, diabetic foot ulcers, pressure ulcers, and arterial ulcers. These types of wounds are called typical wounds, whereas wounds that do not belong to this group are called atypical. We present a comprehensive review in which we describe the concept, epidemiology, clinical manifestations, diagnosis, and treatment of dermatologic wounds.

       This review contains 2 figures, 2 tables and 82 references

      Key Words: atypical wounds, unusual wounds, chronic wounds, typical wounds, dermatological wounds, wound healing, hard-to-heal wounds, trauma, infection.

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    • 2

      Pathophysiology of the Diabetic Foot

      By Paul J Kim, DPM, MS
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      Pathophysiology of the Diabetic Foot

      • PAUL J KIM, DPM, MSProfessor, Vice Chair of Research, MedStar Plastic & Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington DC 20007, United States

      The clinical manifestations of diabetes are evident in the foot. Peripheral neuropathy, peripheral vascular disease, dermatologic alterations, and musculoskeletal changes place the foot at high risk of ulceration. The diabetic foot ulcer (DFU) is the end result of these pathophysiologic changes, which increases the likelihood of infection, hospitalization, and amputation. There are treatment options available, but DFU imparts a tremendous toll on the patient’s quality of life and healthcare resources. Although there is a growing understanding of the pathophysiologic processes unique to the diabetic foot, much work is still needed. This chapter focuses on the assessment and management of the diabetic foot and its associated conditions.

       This review contains 7 figures, 3 tables and 62 references

      Key Words:: Diabetic foot, Diabetic Foot Ulcer, Peripheral Neuropathy, Peripheral Vascular Disease, Foot Wound, Biomechanics, Deformity, Biomechanical Surgery, Infection

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    • 3

      Wound Management and the Utility of Adjunctive Technologies in Diabetic Limb Salvage

      By Tammer Elmarsafi, DPM, MBBCh; John S Steinberg, DPM, FACFAS
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      Wound Management and the Utility of Adjunctive Technologies in Diabetic Limb Salvage

      • TAMMER ELMARSAFI, DPM, MBBCHDiabetic Limb Salvage Fellow, Center for Wound Healing, MedStar Georgetown University Hospital
      • JOHN S STEINBERG, DPM, FACFASProfessor, Department of Plastic Surgery, Georgetown University School of Medicine, Program Director, MedStar Washington Hospital Center Podiatric Residency, Co-Director, Center for Wound Healing, MedStar Georgetown University Hospital

      As the projected prevalence of diabetes worldwide advances, the need for comprehensive treatments becomes paramount. Diabetes is estimated to afflict over 430 million people by the year 2030. It is without question that complications associated with poorly managed diabetes become a threat to the limbs and lives of this cohort. A targeted, specific, and comprehensive algorithm toward the management of lower extremity pathology related to diabetes is an essential public health endeavor. This review is aimed at addressing three key areas: surgical and adjunctive management options for diabetic lower extremity ulcerations, the challenges of lower extremity salvage, and to provide an introduction to the utility of advanced wound management technologies. An emphasis directed at understanding risks and benefits of each modality is discussed. An analysis of available biologic allografts and skin substitutes will be provided in the context of our working knowledge in regenerative medicine and wound treatments.

       

      This review has 5 figures and 45 references

      Key Words: amputation, biologics, debridement, diabetes, infection, , limb salvage, negative pressure wound therapy, peripheral arterial disease, , ulcer

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    • 4

      Treatment of Arterial Ulcers

      By Vahram Ornekian, MD, MS, RPVI; David E Janhofer, BS; Cameron Akbari, MD, MBA, FACS; Karen K Evans, MD
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      Treatment of Arterial Ulcers

      • VAHRAM ORNEKIAN, MD, MS, RPVIChief Resident, Department of Vascular Surgery, MedStar Georgetown University Medical Center, Washington DC, United States,
      • DAVID E JANHOFER, BSResearch Scholar, Department of Plastic Surgery, MedStar Georgetown University Medical Center, Washington DC, United States,
      • CAMERON AKBARI, MD, MBA, FACSAssociate Professor, Department of Vascular Surgery, MedStar Georgetown University Medical Center, Washington DC, United States
      • KAREN K EVANS, MDAssociate Professor, Department of Plastic Surgery, Center for Wound Healing and Hyperbaric Medicine, Washington DC, United States

      Ischemic ulceration of the lower extremity is a challenging problem that requires a careful, systematic approach to achieve healing and favourable outcomes. Ulceration may become limb and life threatening, and limb salvage requires a concerted, multispecialty approach that includes vascular surgeons, plastic surgeons, and podiatrists among others. In this chapter, we propose an algorithm for the evaluation and treatment of ischemic ulceration of the lower extremity. We provide a review of management guidelines, including a discussion of important considerations for appropriate history taking, physical examination evaluation, diagnostic testing modalities, and medical and surgical treatment strategies, taking into account patient functional and ambulatory goals of care.

      This review contains 8 figures, 4 tables and 73 references

      Key Words: amputation, diabetes, ischemic, limb salvage, lower extremity, peripheral arterial disease, reconstruction, revascularization, ulcer, wound

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    • 5

      Biomechanics of the Diabetic Foot

      By Paul J Kim, DPM, MS
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      Biomechanics of the Diabetic Foot

      • PAUL J KIM, DPM, MSProfessor, Vice Chair of Research, MedStar Plastic & Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington DC 20007, United States

      The lower extremity is uniquely equipped to withstand the demands of ambulation that involve a complex orchestration of events to efficiently propel the body forward. The reparative properties and functional capabilities are compromised in the diabetic foot and ankle. Therefore, the diabetic foot is at risk for the development of a chronic ulcer or necessitates the need for an amputation. Unique forces are experienced in the lower extremity during ambulation. Specifically, sagittal and shear forces are less tolerated in the diabetic foot. This chapter discusses the normal and abnormal biomechanics of the diabetic foot and ankle that lead to the development of an ulcer and promote its chronicity. Further, a biomechanical-focused conservative and surgical approach to prevention, treatment, and methods to curtail recidivism will be addressed.

      This review contains 7 figures, 3 tables, and 42 references.

      Key Words: biomechanics, diabetic foot ulcer, foot deformity, function, offloading, plantar pressure, recidivism, shear

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