• Surgery of the Hand
    • 1

      Upper Extremity Compartment Syndrome

      By Jacob M Kirsch, MD; Simon Lee, MD; Jeffrey N Lawton, MD
      Purchase PDF

      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

      Purchase PDF
    • 2

      Reconstruction of the Thumb After Traumatic Tissue Loss

      By James E Clune, MD; Neil F Jones, MD
      Purchase PDF

      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

      Purchase PDF
    • 3

      Common Congenital Hand Differences

      By Francisco Soldado, MD, PhD; Scott Kozin, MD
      Purchase PDF

      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

      Purchase PDF
    • 4

      Vascular Disorders of the Hand

      By Matthew Treiser, MD; Christian E Sampson, MD
      Purchase PDF

      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

      Purchase PDF
    • 5

      Tenosynovitis Disorders of the Hand and Wrist

      By Michael Aversano, MD; Nader Paksima, MD
      Purchase PDF

      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

      Purchase PDF
    • 6

      Flexor Tendon Injuries

      By Chao Long, AB; Lisa C Moody, MD; Paige M Fox, MD, PhD; James Chang, MD
      Purchase PDF

      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

      Purchase PDF
    • 7

      Wrist Fractures and Dislocations

      By Angelo B Lipira, MD; Rahul K Kasukurthi, MD; Jerry I Huang, MD
      Purchase PDF

      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

      Purchase PDF
    • 8

      Microsurgical Reconstruction of the Upper Extremity

      By Nikolas H Kazmers, MD, MSE; Stephanie Thibaudeau, MD; Zvi Steinberger, MD; L. Scott Levin, MD, FACS
      Purchase PDF

      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

      Purchase PDF
    • 9

      Hand Fractures

      By Issei Komatsu, MD; Thomas B Hughes Jr, MD
      Purchase PDF

      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

      Purchase PDF
    • 10

      Hand Infections

      By Scott D Lifchez, MD, FACS; Colton McNichols, MD
      Purchase PDF

      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

      Purchase PDF
  • Principles of Plastic Surgery
    • 1

      Biology of Aging

      By Deepak Bharadia, MD; Raquel Minasian, MD; Indranil Sinha, MD
      Purchase PDF

      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

      Purchase PDF
    • 2

      A Comprehensive Review of Wound Healing

      By Raman Mehrzad, MD, MHL, Postdoctoral Research Fellow; Paul Y Liu, MD, FACS, Professor of Surgery
      Purchase PDF

      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

      Purchase PDF
    • 3

      Biomaterials

      By Pietramaggiori G, MD, PhD; Saja Scherer, MD
      Purchase PDF

      Biomaterials

      • PIETRAMAGGIORI G, MD, PHD Privat Docent University of Lausanne, Global Plastic and Reconstructive Surgery
      • SAJA SCHERER, MDPrivat Docent University of Lausanne, Global Plastic and Reconstructive Surgery, Lausanne

      With the critical advances in material science and bioengineering, the clinical availability of biomaterials is rapidly expanding. Biomaterials are used to restore or correct function of tissues that have been modified by injury, malformation, pathology, or aging. Materials used in contact with living tissues should meet the criteria of biocompatibility, which are (1) biosafety, (2) biofunctionality, and (3) biointegration. Depending on the function they are asked to perform and the target tissue, the choice is among nonresorbable or resorbable biomaterials, metallic or polymeric, and natural or synthetic. Although some materials such as titanium are able to osteointegrate inducing minimal scarring at the interface with living tissues, it seems that a common limitation across all biomaterials is to induce some extent of foreign body reaction and scar encapsulation, which affects negatively the function of the device. Novel surface technologies at the micro- or nano-scale and advanced biomaterials will improve the biointegration of medical devices and allow for permanent implantation of functional biomaterials.

      This review contains 9 figures, 9 tables and 63 references

      Key Words: biocompatibility, biofilm, biofunctionality, biointegration, biomaterials, encapsulation, foreign body reaction, wound healing

      Purchase PDF
    • 4

      Flaps

      By Justin R. Fernandes, MD; Lifei Guo, MD, PhD
      Purchase PDF

      Flaps

      • JUSTIN R. FERNANDES, MDPlastic Surgeon, Lahey Health
      • LIFEI GUO, MD, PHDChairman, Department of Plastic Surgery, Lahey Hospital and Medical Center

      Flaps are the basis for reconstructive surgery and allow the movement of tissue both locally and distantly, to cover wounds, restore form, and reestablish function. Some flap surgeries have been performed for thousands of years; a clear testament to their efficacy. For today’s plastic surgeon, the understanding of flap anatomy and physiology is an absolutely key. This chapter familiarizes the reader with the history and evolution of flap surgery as well as science behind them. We review the multiple classifications for various flap types. We begin with simple, random skin flaps and work up the reconstructive ladder to composite free flaps. Specific flaps will be discussed, including anatomy, operative techniques, and clinical applications. Finally, we examine various ways flaps may be modified to better meet complex reconstructive challenges.

      This review contains 17 figures, 4 tables, 1 video, and 36 references. 

      Key words: Flap, random, pedicled, axial, free, microsurgery, skin, muscle, musculocutaneous, fasciocutaneous, perforator, fabrication, prefabrication, prelamination, supercharging, turbocharging

      Purchase PDF
  • 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
      Purchase PDF

      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 

      Purchase PDF
    • 2

      Abdominal Wall Reconstruction

      By Gregory A. Dumanian, MD, FACS
      Purchase PDF

      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

      Purchase PDF
    • 3

      Transgender Surgery: Female to Male

      By Jonathan P Massie, MD; Shane D Morrison, MD, MS; Curtis N Crane, MD; Mang L Chen, MD
      Purchase PDF

      Transgender Surgery: Female to Male

      • JONATHAN P MASSIE, MDDivision of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
      • SHANE D MORRISON, MD, MSDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
      • CURTIS N CRANE, MDBrownstein & Crane Surgical Services, San Francisco, CA
      • MANG L CHEN, MDMozaic Care, San Francisco, CA

      Gender-confirming surgery is a life-altering and medically necessary set of procedures for some people suffering from gender dysphoria. For transgender men, there are a variety of surgical interventions available for masculinization, including facial, chest, trunk, and genital surgeries. Facial and truncal masculinizations are rarely sought. Chest masculinization is the most common procedure in transgender men and consists of bilateral mastectomy through various approaches dependent on the breast size and laxity with minimal complications. Metoidioplasty and phalloplasty are the most common genital procedures (the radial forearm free flap phalloplasty being the most common) but have significant complication profiles. Up to 40% of those undergoing genital masculinization suffer from urethral fistula or stricture. Current advances consist of neurotization of the phallus and implant placement. Future studies on patient-reported outcomes and long-term follow-up are needed.

      This review contains 16 figures, 3 tables, and 62 references. 

      Key Words: chest masculinization, gender affirmation, metoidioplasty, penile implant, phalloplasty, radial forearm free flap, scrotoplasty, transgender, urethral fistula, vaginectomy

      Purchase PDF
    • 4

      Penile Reconstruction

      By Shane D Morrison, MD, MS; Afaaf Shakir, MD; Christopher S Crowe, MD; Gordon K Lee, MD, FACS
      Purchase PDF

      Penile Reconstruction

      • SHANE D MORRISON, MD, MSDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
      • AFAAF SHAKIR, MDPlastic Surgery Resident, Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Chicago, IL
      • CHRISTOPHER S CROWE, MDPlastic Surgery Resident, Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
      • GORDON K LEE, MD, FACSProfessor of Plastic Surgery, Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA

      Total penile reconstruction aims to either reestablish a functioning phallus in men who have suffered traumatic amputation or are born with congenital anomalies or to create a neophallus in female to male transgender patients as part of their gender-confirmation surgery. Reconstructive and functional goals include the ability to void while standing, having erogenous sensation of the tissue, and having the ability to engage in penetrative sexual intercourse. Several techniques for total phalloplasty exist, which include both microsurgical and non-microsurgical approaches. In this review chapter, we outline the most common techniques, provide recent data on patient outcomes, and review operative considerations.

      This review contains 14 figures, 1 table, and 84 references.

      Key Words: aphallia, bottom surgery, female-to-male, neophallus, penile reconstruction, perineal reconstruction, phallus, transgender surgery

      Purchase PDF
  • Head and Neck Reconstruction
    • 1

      Reconstructive Approaches to Nasal Defects

      By Ravi K Garg, MD; Michael L Bentz, MD
      Purchase PDF

      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

      Purchase PDF
    • 2

      Hypopharyngeal, Esophageal, and Neck Reconstruction

      By Steven B Chinn, MD MPH; Peirong Yu, MD
      Purchase PDF

      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

      Purchase PDF
    • 3

      Head and Neck Melanoma: an Overview

      By Samuel Kim, MD; Deepak Narayan, MD
      Purchase PDF

      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

      Purchase PDF
    • 4

      Facial Transplantation

      By Mario A Aycart, MD; Bohdan Pomahac, MD
      Purchase PDF

      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

      Purchase PDF
    • 5

      Midface Reconstruction

      By William J. Rifkin, BA; Jesus Rodrigo Diaz-Siso, MD; Eduardo D. Rodriguez, MD, DDS
      Purchase PDF

      Midface Reconstruction

      • WILLIAM J. RIFKIN, BAPre-doctoral Research Fellow, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
      • JESUS RODRIGO DIAZ-SISO, MDPostdoctoral Research Fellow, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
      • EDUARDO D. RODRIGUEZ, MD, DDSHelen L. Kimmel Professor of Reconstructive Plastic Surgery, Chair, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY

      Composite defects of the midface present a formidable reconstructive challenge. Progress in craniomaxillofacial surgery has led to improved understanding of the functional role of skeletal subunits, whereas microsurgical free tissue transfer has become a reliable means for soft tissue coverage of large facial wounds. Although historically divergent, the intersection of these subspecialties has provided surgeons with the resources to undertake complex reconstructive problems in an anatomic location where functional and aesthetic concerns are equally critical. Technological advances have allowed teams to plan procedures in precise detail, increasing surgical accuracy and creating optimal conditions for long-term oral rehabilitation. Interestingly, far from obsoleting them, these innovations reinforce the age-old surgical principles that have guided facial reconstruction for the past century. Perhaps the ultimate representation of these principles, facial transplantation has transformed even the most severe craniomaxillofacial defects into reconstructible problems; special considerations must be recognized when reconstructing the skeletal structures of the midface in the context of allotransplantation.

      This review contains 7 figures and 29 references.

      Key Words: aesthetic units, composite facial defects, facial transplantation, free fibula flap, free iliac bone flap, midface reconstruction, skeletal buttresses, staged reconstruction

      Purchase PDF
  • Congenital Anomalies of the Head and Neck
    • 1

      Vascular Anomalies

      By Javier A Couto, MD; Arin K Greene, MD, MMSc
      Purchase PDF

      Vascular Anomalies

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

      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

      Purchase PDF
    • 2

      Distraction Osteogenesis in Plastic Surgery

      By Elizabeth G Zellner, MD; Derek M Steinbacher, DMD, MD, FACS
      Purchase PDF

      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.

      Purchase PDF
    • 3

      Cleft Palate

      By Oksana A Jackson, MD; Alison E Kaye, MD; David W Low, MD
      Purchase PDF

      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

      Purchase PDF
    • 4

      Orthognathic Surgery

      By Howard D Wang, MD; Robin Yang, MD, DDS; Joseph Lopez, MD, MBA; Edward W Swanson, MD; Amy Quan, MPH; Anand R Kumar, MD
      Purchase PDF

      Orthognathic Surgery

      • HOWARD D WANG, MDResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
      • ROBIN YANG, MD, DDSResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
      • JOSEPH LOPEZ, MD, MBAResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
      • EDWARD W SWANSON, MDResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
      • AMY QUAN, MPHMedical Student, Johns Hopkins School of Medicine, Baltimore, MD
      • ANAND R KUMAR, MDAssociate Professor, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD

      Orthognathic surgery describes the surgical movement of the mandible and maxilla to correct dentofacial deformities that result from congenital or traumatic etiologies. Patients with dentofacial deformity often have malocclusion and functional problems related to breathing, chewing, or speech articulation. Furthermore, facial asymmetries or disproportions resulting from dentofacial deformities can adversely affect the psychosocial health of the patient. The goal of orthognathic surgery is to improve both function and form beyond what can be achieved with orthodontic or medical treatments. Some of the most commonly performed orthognathic surgery procedures include Le Fort I osteotomy of the maxilla, bilateral sagittal split osteotomy of the mandible, and genioplasty. Successful outcome after orthognathic surgery should be judged by achieving an improved dental occlusion, enhanced facial aesthetics, and open upper airway. A number of studies have shown that orthognathic surgery leads to significant improvements in the quality of life of patients with dentofacial deformities. Orthognathic surgery also has a significant impact on the upper airway. In patients with severe obstructive sleep apnea, maxillomandibular advancement has the potential to lead to dramatic improvements in the apnea-hypopnea index and lowest oxygen saturation value. With careful surgical planning and execution, consistent outcomes can be expected.

      This review contains 17 figures, 4 tables, and 32 references.

      Key Words: aesthetic surgery, dentofacial deformity, genioplasty, Le Fort I, malocclusion, orthognathic surgery, sagittal split osteotomy of the mandible, sleep apnea, virtual surgical planning

      Purchase PDF
    • 5

      Management of Speech and Swallowing Disorders in Children With Oral Clefts

      By Ravi K. Garg, MD; Delora L Mount, MD
      Purchase PDF

      Management of Speech and Swallowing Disorders in Children With Oral Clefts

      • RAVI K. GARG, MDResident Physician, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
      • DELORA L MOUNT, MDAssociate Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin

      Cleft lip and palate are common congenital anomalies with significant implications for feeding, swallowing, and speech. If a cleft palate goes unrepaired, a child will have difficulty distinguishing nasal and oral sounds. Even following cleft palate repair, approximately 20 to 30% of nonsyndromic children have persistent hypernasal speech. This often occurs due to velopharyngeal dysfunction (VPD), a term describing failure of the soft palate and pharyngeal walls to seal the nasopharynx from the oropharynx during oral consonant production. The gold standard for diagnosis is perceptual examination by a trained speech pathologist, although additional diagnostic tools such as nasendoscopy are often used. Treatment options for VPD range from speech therapy to revision palatoplasty, sphincter pharyngoplasty, pharyngeal flap, and pharyngeal wall augmentation. Palatal prosthetics may also be considered for children who are not surgical candidates. Further research is needed to improve selection of diagnostic and treatment interventions and optimize speech outcomes for children with a history of oral cleft.

      This review contains 1 figure, 3 videos, and 58 references. 

      Key words: Cleft lip and palate, hypernasal resonance, levator veli palatine, nasal emission, nasendoscopy, palatoplasty, pharyngeal flap, posterior pharyngeal wall augmentation, sphincter pharyngoplasty, velopharyngeal dysfunction

      Purchase PDF
  • Cosmetic Surgery
    • 1

      Minimally Invasive Approaches to Forehead Rejuvenation

      By Dhivya R Srinivasa, MD; Paul S Cederna, MD
      Purchase PDF

      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.

      Purchase PDF
    • 2

      Upper Blepharoplasty

      By Tiffany N Ballard, MD; Robert H Gilman, MD, DMD
      Purchase PDF

      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

      Purchase PDF
    • 3

      Hair Transplantation: Biochemical Basis and Surgical Treatment

      By Richard J. Ehrlichman, MD, FACS; Allan J. Parungao, MD, FACS
      Purchase PDF

      Hair Transplantation: Biochemical Basis and Surgical Treatment

      • RICHARD J. EHRLICHMAN, MD, FACSInstructor in Surgery, Harvard Medical School, Boston, MA, Assistant in Surgery, Massachusetts General Hospital, Boston, MA
      • ALLAN J. PARUNGAO, MD, FACSSurgeon, Bosley Medical, Chicago, IL

      Modern day hair transplantation has undergone tremendous advances since the understanding of the patterns of male hair loss and miniaturization related to androgenic alopecia caused by DHT (dihydrotesterone).  The concept of donor dominance, in which hairs genetically resistant to the effects of DHT can be moved to other locations where hair has been lost due to sensitivity to this hormone, is the basis for modern day hair transplantation.  Early hair transplantation based on this knowledge involved moving plugs of hair from DHT resistant hairs posteriorly to the anterior hairline.  These however resulted in abnormal hairlines which did not appear natural.  Presently, hair transplantation is placed on the use of 1, 2, 3, and 4 hair follicular units to create more natural hairlines.  In addition, knowledge of the biochemistry of hair loss has resulted in nonsurgical treatments that can regrow and maintain hair.  Finasteride (Propecia) and minoxidil (Rogaine) are now important adjuncts before, during and after hair transplantation.  Advances have been made in the harvesting of donor hair including the use of follicular unit extraction which removes individual 1, 2, 3 or 4 hair follicular units and the use of robots for extraction.  Because of the limitations of donor sites and the fact that hair loss is progressive, future research will involve the use of stem cells.

      This review contains 27 figures and 106 references.

      Key Words: androgenic alopecia, cicatricial alopecia, DHT, donor dominance, follicular units, miniaturization, stem cells, telogen effluvium, trichophytic

      Purchase PDF
  • Surgery of the Breast
    • 1

      Breast Augmentation

      By Eric J. Culbertson, MD; William P. Adams Jr, MD
      Purchase PDF

      Breast Augmentation

      • ERIC J. CULBERTSON, MDBody and Breast Cosmetic Surgeon, The Jacobs Center for Cosmetic Surgery, Healdburg, CA
      • WILLIAM P. ADAMS JR, MDProgram Director at UT Southwestern Aesthetic Surgery Fellowship, Associate Professor at UT Southwestern Dept. of Plastic Surgery, Education Commissioner at The Aesthetic Society

      Breast augmentation is a complicated process that goes far beyond placing an implant in a pocket. The implants and techniques of breast augmentation have undergone significant evolution over the past 50 years, and this is now one of the most commonly performed cosmetic procedures worldwide. Advancements in shell barrier technology and silicone form stability have improved implant functional characteristics and mechanical properties. Tissue-based planning uses measurable patient characteristics to match an implant to the patient’s tissue for greater control of the aesthetic result while minimizing complications. The realization of three-dimensional modeling systems allows a more sophisticated approach to implant selection and establishment of patient expectations. Specific surgical techniques, including pocket plane and incision location, ensure ideal implant placement. Optimal patient outcomes are achieved by integrating patient education, implant selection with tissue-based planning, refined surgical technique, and detailed postoperative recovery. 

      This review contains 12 figures, 6 tables, 1 video, and 74 references.

      Key Words: breast augmentation, breast implants, breast implant-associated anaplastic large cell lymphoma, dual plane, capsular contracture, saline implants, silicone implants, tissue-based planning, three-dimensional imaging 

      Purchase PDF
  • Wound Healing
    • 1

      Dermatologic Wounds

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

      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.

      Purchase PDF
    • 2

      Pathophysiology of the Diabetic Foot

      By Paul J Kim, DPM, MS
      Purchase PDF

      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

      Purchase PDF
    • 3

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

      By Tammer Elmarsafi, DPM, MBBCh; John S Steinberg, DPM, FACFAS
      Purchase PDF

      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

      Purchase PDF
    • 4

      Treatment of Arterial Ulcers

      By Vahram Ornekian, MD, MS, RPVI; David E Janhofer, BS; Cameron Akbari, MD, MBA, FACS; Karen K Evans, MD
      Purchase PDF

      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

      Purchase PDF
    • 5

      Biomechanics of the Diabetic Foot

      By Paul J Kim, DPM, MS
      Purchase PDF

      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

      Purchase PDF
    • 6

      Cutaneous Scarring

      By Rei Ogawa, MD, PhD, FACS; Dennis P Orgill, MD, PhD
      Purchase PDF

      Cutaneous Scarring

      • REI OGAWA, MD, PHD, FACSDepartment of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
      • DENNIS P ORGILL, MD, PHDDivision of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Keloids and hypertrophic scars are caused by cutaneous injury and irritation, including trauma, insect bite, burn, surgery, vaccination, skin piercing, acne, folliculitis, chicken pox, and herpes zoster infection. Notably, superficial injuries that do not reach the reticular dermis never cause keloid and hypertrophic scarring. This suggests that these pathologic scars are due to injury to this skin layer and the subsequent aberrant wound healing therein. Various external and internal postwounding stimuli may promote reticular inflammation. Specifically, it is likely that the intensity, frequency, and duration of these stimuli determine how quickly the scars appear, the direction and speed of growth, and the intensity of symptoms. These proinflammatory stimuli include a variety of local, systemic, and genetic factors. At present, physicians cannot (or at least find it very difficult to) control systemic and genetic risk factors of keloids and hypertrophic scars. However, they can use a number of treatment modalities that all, interestingly, act by reducing inflammation. These include corticosteroid injection or tape or ointment, radiotherapy, compression therapy, stabilization therapy, and surgical methods that reduce skin tension.

      This review contains 11 figures and 41 references.

      Key Words: atrophic scar, hypertrophic scar, keloid, mature scar, pathologic scar, wound healing

      Purchase PDF
    • 7

      Venous Stasis Disease

      By Allyson R Alfonso, BS, BA; Daniel Cuzzone, MD; Ernest S Chiu, MD, FACS
      Purchase PDF

      Venous Stasis Disease

      • ALLYSON R ALFONSO, BS, BAMedical Student, New York University School of Medicine, New York, NY
      • DANIEL CUZZONE, MDResident, HansjörgWyss Department of Plastic Surgery, NYU Langone Health, New York, NY
      • ERNEST S CHIU, MD, FACSAssociate Professor of Plastic Surgery, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY

      Chronic venous disease (CVD) is a chronic and morbid condition with a wide pathologic spectrum. The common denominator is either impaired venous outflow or anomalous (retrograde) venous inflow most often related to a failure of the valvular system. Diagnosis is made with a thorough history, physical examination, and imaging such as duplex ultrasonography. The disease can then be classified using the Clinical, Etiology, Anatomic, Pathophysiology classification system and Venous Clinical Severity Score. Management is based on disease etiology and symptomatic presentation. It is important to first identify the presence or absence of venous ulceration. In venous ulceration, compression therapy with contact dressings is standard therapy, but surgical wound debridement and skin or fat grafting can be necessary for wound closure. Additional operative treatment for those with CVD can include conservative hemodynamic correction of venous insufficiency, vein stripping, and endovenous thermal ablation. With multiple etiologies and subsequent treatment options, CVD requires patient and vigilant care on part of the patient and the treating clinician. Although much is known about CVD, our ability to predict, prevent, and treat is limited by aspects of the disease in need of further study.

      This review contains 8 figures, 6 tables, and 51 references.

      Key Words: chronic venous disease, chronic venous insufficiency, venous ulcer, wound healing, venous physiology, venous ulcer management, compression therapy, wound contact dressings, surgical management 

      Purchase PDF
  • Competency-based Patient Care
    • 1

      Surgical Palliative Care

      By Zara Cooper, MD, MSc, FACS; Emily B. Rivet, MD, MBA, FACS, FASCS
      Purchase PDF

      Surgical Palliative Care

      • ZARA COOPER, MD, MSC, FACSAssistant Professor of Surgery, Harvard Medical School, Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA
      • EMILY B. RIVET, MD, MBA, FACS, FASCSAssistant Professor, Department of Surgery Brigham and Women’s Hospital, Harvard Medical School

      Palliative care is a multidisciplinary approach to care that includes relief of suffering and attention to the social, spiritual, physical, and psychological needs of patients and families. The intent of palliative care is to help patients live as well as possible for as long as possible, and relevant domains of palliative care include symptom relief, prognostication, communication with patients, families and clinicians, transitions of care, and end-of-life care. Palliative care is distinct from hospice in many respects including that it can be provided simultaneously with recovery-directed treatments rather than reserved for individuals at end of life. Patients with surgical disease are particularly in need of palliative care due to the common occurrence of severe symptoms such as pain and nausea, complex decision-making, and the often sudden onset of the disease or injury which precludes preparation for the new health state.

      This review contains 3 figures, 10 tables, and 61 references.

      Key Words: communication, end-of- life, goals of care, high-risk surgery, palliative, palliative care, palliative surgery, patient comfort, surgical decision-making, surgical prognostication

      Purchase PDF
    • 2

      Minimizing Vulnerability to Malpractice Claims

      By William R Berry, MD, MPH, FACS; Janaka Lagoo, MD
      Purchase PDF

      Minimizing Vulnerability to Malpractice Claims

      • WILLIAM R BERRY, MD, MPH, FACSResearch Associate, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
      • JANAKA LAGOO, MDSurgical Research Fellow, Ariadne Labs, Boston, MA

      This review provides strategies for avoiding lawsuits and advice for dealing with a lawsuit if one is ever filed. Medical malpractice is explained, as are the personal issues for the defendant physician. Strategies for preventing malpractice suits are presented, including those relative to communication and interpersonal skills, the informed consent process, and documentation. Advice is provided for what surgeons should do if sued or threatened with a lawsuit, including measures for assisting in the defense and settling claims versus trying a case. Preparing for a deposition is discussed. How a surgeon should act when serving as a defendant or witness in a courtroom trial is presented.

      This review contains 5 tables, and 23 references.

      Key words: claim, communication, defendant, informed consent, lawsuit, malpractice, medical records, negligence, suit

      Purchase PDF
    • 3

      Understanding Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS
      Purchase PDF

      Understanding Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssociate Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor, MI, United States; Associate Professor of Management and Organizations, University of Michigan Stephen M. Ross School of Business, Ann Arbor, MI, United States; Director, Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, United States; Surgical Director, University Hospital, Michigan Medicine, Ann Arbor, MI, United States

      This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety.

      This review contains 3 figures, 3 tables, and 78 references

      Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations


      Purchase PDF
    • 4

      Improving Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS
      Purchase PDF

      Improving Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssociate Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor, MI, United States; Associate Professor of Management and Organizations, University of Michigan Stephen M. Ross School of Business, Ann Arbor, MI, United States; Director, Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, United States; Surgical Director, University Hospital, Michigan Medicine, Ann Arbor, MI, United States

      This chapter outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries.

      This review contains 1 figures, 4 tables, and 84 references


      Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork


      Purchase PDF
    • 5

      Health Economics: National Health Care Expenditures

      By Bruce L Hall, MD, PhD, MBA, FACS
      Purchase PDF

      Health Economics: National Health Care Expenditures

      • BRUCE L HALL, MD, PHD, MBA, FACSProfessor of Surgery, School of Medicine, Professor of Healthcare Management, Olin Business School, Washington University, Saint Louis, MO, United States, Vice President and Chief Quality Officer, BJC Healthcare, Saint Louis MO, United States

      A picture of the overall structure of the US health care industry can be garnered by examining national health expenditures. In 2015, US national health expenditures grew to $3.2 trillion (US), outpacing growth in gross domestic product. Valuable insights are found by examining categories of spending, sources of funds, and target areas of spending, raising questions about the logic and performance of the US system. These perspectives can inform deeper consideration of healthcare policy and reform.

      This review contains 3 tables and 20 references.

      Key Words: health economics, health policy, Medicaid, Medicare, national health expenditures, opportunity cost, projections

      Purchase PDF
    • 6

      Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance

      By Bruce L Hall, MD, PhD, MBA, FACS
      Purchase PDF

      Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance

      • BRUCE L HALL, MD, PHD, MBA, FACSProfessor of Surgery, School of Medicine, Professor of Healthcare Management, Olin Business School, Washington University, Saint Louis, MO, United States, Vice President and Chief Quality Officer, BJC Healthcare, Saint Louis MO, United States

      The production of health as an output of various inputs is a key concept of health care economics and a key influence on health care policy. Similarly, the notion of risk—that an outcome might not turn out as expected or hoped—underpins the entire theory of insurance. Insurance, and the benefits it can provide, cannot be understood without understanding risk, or without understanding how the features of an insurance contract transform risk for the individual, the payer, or society. The health economist, policy maker, leader, expert operator, financier, insurer, clinician of any stripe, patient or family or advocate, or other interested stakeholder must always consider the structural, clinical, and economic anatomy of health care in the context of the underlying physiology of these economic concepts.

      This review contains 2 figures, 1 table, and 14 references.

      Key Words: health economics, health policy, health production, marginal return (diminishing), utility, inputs, QALY, risk (aversion or tolerance), insurance (contract features)

      Purchase PDF
    • 7

      Bedside Procedures for General Surgeons: Part 1

      By Thomas H. Cogbill, MD; Basem S Marcos, MD
      Purchase PDF

      Bedside Procedures for General Surgeons: Part 1

      • THOMAS H. COGBILL, MDProgram Director Emeritus, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI
      • BASEM S MARCOS, MD

      This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged.

      This review contains 19 figures, 7 tables, and 33 references.

      Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

      Purchase PDF
    • 8

      Bedside Procedures for General Surgeons: Part 2

      By Thomas H. Cogbill, MD; Basem S Marcos, MD
      Purchase PDF

      Bedside Procedures for General Surgeons: Part 2

      • THOMAS H. COGBILL, MDProgram Director Emeritus, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI
      • BASEM S MARCOS, MD

      This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged.

      This review contains 24 figures, 9 tables, and 33 references.

      Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy

      Purchase PDF
Feedback
Updates per yearSpecialty updatesNumber of sections