- Competency-based Patient Care
Surgical Palliative Care
By Zara Cooper, MD, MSc, FACS; Emily B. Rivet, MD, MBA, FACS, FASCSPurchase PDF
Surgical Palliative CarePurchase PDF
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
Minimizing Vulnerability to Malpractice Claims
By William R Berry, MD, MPH, FACS; Janaka Lagoo, MDPurchase PDF
Minimizing Vulnerability to Malpractice ClaimsPurchase PDF
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
Understanding Patient Safety in Surgical Care
By Amir Ghaferi, MD, MS, FACSPurchase PDF
Understanding Patient Safety in Surgical CarePurchase PDF
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
Improving Patient Safety in Surgical Care
By Amir Ghaferi, MD, MS, FACSPurchase PDF
Improving Patient Safety in Surgical CarePurchase PDF
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
Health Economics: National Health Care Expenditures
By Bruce L Hall, MD, PhD, MBA, FACSPurchase PDF
Health Economics: National Health Care ExpendituresPurchase PDF
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
Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance
By Bruce L Hall, MD, PhD, MBA, FACSPurchase PDF
Health Economics: Select Concepts of the Health Production Function, Risk, and InsurancePurchase PDF
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)
Bedside Procedures for General Surgeons: Part 1
By Thomas H. Cogbill, MD; Basem S Marcos, MDPurchase PDF
Bedside Procedures for General Surgeons: Part 1Purchase PDF
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
Bedside Procedures for General Surgeons: Part 2
By Thomas H. Cogbill, MD; Basem S Marcos, MDPurchase PDF
Bedside Procedures for General Surgeons: Part 2Purchase PDF
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
Coronaviruses: Hcov, Sars-cov, Mers-cov, and COVID-19
By Michael G. Ison, MD, MScPurchase PDF
Coronaviruses: Hcov, Sars-cov, Mers-cov, and COVID-19Purchase PDF
Coronaviruses (CoVs) are a group of viral pathogens that infect mammals and birds. The presentation in humans is typically that of a mild upper respiratory tract infection, similar to the common cold. However, in recent years, dramatic attention has arisen for more lethal members of this viral family (e.g., severe acute respiratory syndrome [SARS-CoV], Middle East respiratory syndrome [MERS-CoV], and coronavirus disease 2019 [COVID-19]). The epidemiology, clinical presentation, diagnosis, and management of these viruses are discussed in this review. Importantly, new guideline tables from the Centers for Disease Control and Prevention, as well as the World Health Organization are provided at the conclusion of the review.
This review contains 12 tables, 3 figure and 48 references.
Keywords: Coronavirus, severe acute respiratory distress syndrome (SARS), Middle East respiratory syndrome (MERS), COVID-19, respiratory infection, antiviral, real-time polymerase chain reaction
Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice
By Sonali P. Desai, MD, MPH; Allen Kachalia, MD, JDPurchase PDF
Quality of Care: Performance Measurement and Quality Improvement in Clinical PracticePurchase PDF
- Principles of Plastic Surgery
Biology of Aging
By Deepak Bharadia, MD; Raquel Minasian, MD; Indranil Sinha, MDPurchase PDF
Biology of AgingPurchase PDF
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
A Comprehensive Review of Wound Healing
By Raman Mehrzad, MD, MHL, Postdoctoral Research Fellow; Paul Y Liu, MD, FACS, Professor of SurgeryPurchase PDF
A Comprehensive Review of Wound HealingPurchase PDF
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
By Pietramaggiori G, MD, PhD; Saja Scherer, MDPurchase PDF
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
By Justin R. Fernandes, MD; Lifei Guo, MD, PhDPurchase PDF
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
By Deniz Sarhaddi, MD; Foad Nahai, MDPurchase PDF
Aesthetic PrinciplesPurchase PDF
The perception of beauty impacts our daily lives, such that the pursuit of beauty is often the pursuit of an improved quality of life. Although there are guidelines for facial proportions, there is no set beauty ideal in the modern day. Aesthetic surgeons should be familiar with facial proportions and should be able to modify these with respect to cultural and ethnic variations. To achieve imperceptible scarring, aesthetic surgeons should be able to control tissue tension, properly orient incisions, appreciate anatomical subunits, and avoid distortion of surrounding structures. Aesthetic surgery, when performed with craftsmanship, can achieve a long-lasting and harmonious result.
This review contains 10 figures, and 26 references.
Keywords: defining beauty, facial aesthetic proportions, facial subunits, scarring, resting skin tension lines, evolution of facelift, SMAS, facial aging
Grafting – Basic Principles and Surgical Applications, Part I
By Dominic Henn, MD; Kellen Chen, PhD; Janos A. Barrera, MD; Jagannath Padmanabhan, PhD; Sun Hyung Kwon, PhD; Geoffrey C. Gurtner, MDPurchase PDF
Grafting – Basic Principles and Surgical Applications, Part IPurchase PDF
Grafting is defined as a surgical procedure in which tissue is transplanted without its native blood supply from one anatomic region of the body to another. A graft can be transplanted within the same individual (autograft), or between individuals of the same (allograft) or a different species (xenograft). A graft fully relies on the blood supply of its recipient site, which is why healthy and well vascularized recipient sites are prerequisites for successful graft healing. Various types of tissues can be grafted with reliable healing rates and have become part of standard surgical treatment strategies. Pre-clinical research approaches within tissue engineering and regenerative medicine using stem cells, biological scaffolds, biomolecules, and gene therapy have demonstrated great advances in graft vascularization and healing and may yield translational treatment strategies improving patient outcomes in the future.
This review contains 3 figures, and 48 references.
Keywords: autograft, allograft, xenograft, vascularization, skin grafting, fat grafting, tissue engineering, regenerative medicine
Grafting – Basic Principles and Surgical Applications, Part II
By Dominic Henn, MD; Kellen Chen, PhD; Janos A. Barrera, MD; Jagannath Padmanabhan, PhD; Sun Hyung Kwon, PhD; Geoffrey C. Gurtner, MDPurchase PDF
Grafting – Basic Principles and Surgical Applications, Part IIPurchase PDF
Grafting of blood vessels and nerves are essential surgical techniques which are used to restore continuity in cases of acute or chronic vascular or nervous damage. Due to superior outcomes autologous grafts are generally preferred over allografts or alloplastic grafts. Bone, cartilage and tendons are physiologically subjected to various degrees of mechanical stress, which has been observed to play a critical role in graft survival and remodeling. Bone grafting is used to replace missing bone or to enhance new bone formation in the treatment of fractures, delayed or non-unions or in reconstructive surgery after trauma or tumor resection. Unlike bone, cartilage and tendons have a low capacity for self-renewal due their avascular nature and low cellularity which presents challenges to graft survival and healing rates.
This review contains 2 figures, and 68 references.
Keywords: autograft, allograft, vascular grafting, nerve grafting, bone grafting, cartilage grafting, tendon grafting, tissue engineering, regenerative medicine
By Shannon Malloy, BS; Laura Nuzzi, BA; Catherine McNamara, BS; Brian Labow, MDPurchase PDF
Tissue ExpansionPurchase PDF
Tissue expansion is a well-recognized surgical technique vastly used throughout reconstructive plastic surgery which encourages creation and recruitment of local soft tissues for reconstructive purposes. The most common indications for tissue expansions are burns, pigmented legions, and breast reconstruction. Expansion involves placing a subcutaneous prosthesis called an expander in the area of interest and slowly enlarging the expander with saline over a period of six to twelve weeks. Tissue expansion is a relatively safe procedure used to resolve defects in both adults and children with low complication rates. New innovations such as inflating with carbon dioxide in place of saline and using three-dimensional analysis to customize expanders for each patient work to reduce pain, increase expansion control, and optimize the tissue expansion experience.
This review contains 9 figures, 4 tables, and 40 references.
Keywords: tissue, tissue expansion, reconstructive surgery, expander, saline injection, burns, breast reconstruction, large congenital nevi
Developmental Biology I: Bone Development, Repair, and Regeneration
By Mimi R. Borrelli, MD; Ledibabari M. Ngaage, MD; Derrick C. Wan, MD; Michael T. Longaker, MD; H. Peter Lorenz, MDPurchase PDF
Developmental Biology I: Bone Development, Repair, and RegenerationPurchase PDF
Defects of the skeletal system are extremely common and amount to a significant biomedical burden. Bone is a unique tissue that retains its regenerative potential into adulthood. The biology behind bone development, repair, and regeneration is thus of considerable interest, and may lead to advances in patient care. There are two distinct forms of osteogenesis; bones of the craniofacial skeleton develop via intramembranous ossification, whilst bones of the appendicular skeleton form by endochondral ossification. In this review, bone regenerative mechanisms based on skeletal stem cell function during fracture repair and during distraction osteogenesis are reviewed. Skeletal stem cell function more closely follows developmental mechanisms during distraction osteogenesis compared to fracture osteogenesis.
This review contains 5 figures and 50 references.
Keywords: skeletal stem cell, osteogenesis, skeletogenesis, mechanotransduction, regeneration, remodeling, focal adhesion kinase, ossification
Developmental Biology II: the Role of WNT Signaling in Bone Regeneration
By Mimi R. Borrelli, MD; Ledibabari M. Ngaage, MD; Derrick C. Wan, MD; Michael T. Longaker, MD; H. Peter Lorenz, MDPurchase PDF
Developmental Biology II: the Role of WNT Signaling in Bone RegenerationPurchase PDF
Wingless-related integration site (Wnt) signaling is an important regulator of bone development and regeneration. Wnts are short-range signaling molecules which act within the skeletal stem cell niche to influence cell proliferation and differentiation. Nineteen different Wnts have been identified in humans. Disruptions to Wnt signaling can lead to impairments in bone healing. Recent work has elucidated the complexities of Wnt signaling during bone development, repair, and regeneration, and highlighted its value as a potential therapeutic target for tissue regeneration. Here, we discuss the role of the canonical-Wnt-signaling pathway, its regulatory role in bone regeneration, and the recent clinical advance made towards its manipulation in regenerative medicine.
This review contains 3 figures and 50 references.
Keywords: osteogenesis, bone regeneration, bone remodeling, endochondral ossification, osteoblast, osteoprogenitor, lithium, fracture healing
By Maria Siemionow, MD, PhD, DSc; Fatih Zor, MDPurchase PDF
Transplantation PrinciplesPurchase PDF
Transplantation is a truly multidisciplinary specialty where a surgical procedure requires inputs from both, the specialists of the specific organ e.g. nephrologist for kidney transplant or hepatologist for liver transplant, as well as from experts of other specialties such as immunology, infectious diseases etc. It is also a rapidly grooving field with the advances in surgical techniques, immunological knowledge and pharmacology. A recent, major advance in the field of transplantation is the emergence of new procedure of vascularized composite allotransplantation, which includes transplantation of non-lifesaving organs such as face, hands, abdominal wall or uterus. Additionally, organ shortage in transplantation yielded a new area of research such as xenotransplantation and regenerative medicine. The specialty of transplantation may be difficult to comprehend for those entering the field; thus, the goal of this chapter is to provide a comprehensive overview of the most important aspects of transplantation.
This review contains 2 figures, 3 tables, and 67 references.
Keywords: transplantation, solid organ transplantation (SOT), vascularized composite allotransplantation (VCA), transplant immunology, allorecognition, acute rejection, chronic transplant rejection, principles of transplantation, transplantation terminology, immunosuppressive drugs
By Britlyn D. Orgill, MD; Douglas L. Helm, MDPurchase PDF
Anesthetic PrinciplesPurchase PDF
Advances in anesthesia have expanded the field of plastic surgery by allowing more procedures to be done, while also increasing the safety of the patient. Anesthesia is a spectrum ranging from local anesthetic injected by the surgeon, to regional and neuraxial blocks or general anesthesia with an anesthesia team. Anesthesiologists work with the surgeon to assess a patient’s preoperative risk and make joint decisions to determine if additional medical optimization is needed prior to surgery. New peripheral blocks allow alternatives to general anesthesia or serve as adjuncts to improve post-operative pain. Selection of drugs used to induce and maintain anesthesia are changing with the advent of Enhanced Recovery After Surgery Protocols and emphasis on decreasing opioids. Teamwork and excellent communication are imperative to navigate anesthetic and surgical emergencies.
This review contains 3 figures, 4 tables, and 29 references.
Keywords: sedation, general anesthesia, regional anesthesia, peripheral nerve blocks, local anesthetic toxicity syndrome, ASA physical status, preoperative fasting guidelines, opioids, multi-modal analgesia, ERAS, crisis checklists
- Trunk and Perineal Reconstruction
Male-to-female Gender-confirming Surgery
By Shane D Morrison, MD, MS; Stelios C Wilson, MD; Marcelina G Perez, Medical Student; Thomas Satterwhite, MDPurchase PDF
Male-to-female Gender-confirming SurgeryPurchase PDF
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
Abdominal Wall Reconstruction
By Gregory A. Dumanian, MD, FACSPurchase PDF
Abdominal Wall ReconstructionPurchase PDF
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
Transgender Surgery: Female to Male
By Jonathan P Massie, MD; Shane D Morrison, MD, MS; Curtis N Crane, MD; Mang L Chen, MDPurchase PDF
Transgender Surgery: Female to MalePurchase PDF
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
By Afaaf Shakir, MD; Shane D Morrison, MD, MS; Christopher S Crowe, MD; Gordon K Lee, MD, FACSPurchase PDF
Penile ReconstructionPurchase PDF
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
Nerve Reconstruction and Tendon Transfers for Treatment of Brachial Plexus Injuries
By Christopher J. Dy, MD MPH FACS; David M. Brogan, MD MSc; Martin I. Boyer, MD MSc FRCS(C); Carol B. Loeb; Jerome T. LoebPurchase PDF
Nerve Reconstruction and Tendon Transfers for Treatment of Brachial Plexus InjuriesPurchase PDF
The complexity of each brachial plexus injury (BPI) pattern and physiologic limitations of nerve regeneration create challenges for BPI patients and their surgeons. Detailed assessment via physical examination, electrodiagnostic studies, and advanced imaging can aid the surgeon in predicting the prognosis for each patient’s neurologic recovery and provide an outline for reconstructive priorities. Surgical exploration of the brachial plexus confirms the injury pattern and guides the overall treatment strategies. A multimodal reconstructive strategy including nerve grafting, extraplexal nerve transfers, distal intraplexal nerve transfers, and free-functioning muscle transfers is designed for each patient to accomplish the goals of providing a pain-free helper hand. Additional reconstructive procedures such as tendon transfers and selective joint arthrodeses are used after the results of the initial reconstructive efforts have been declared. Beyond the neurologic components of BPI, the surgeon must be attuned to the social and psychological sequelae of this devastating injury.
This review contains 10 figures, 1 table, and 60 references.
Key Words: brachial plexus injury, elbow flexion, free-functioning muscle transfer, nerve grafting, nerve transfer, reconstruction, shoulder abduction, , tendon transfer
Reconstruction of the Abdominal Wall With Mesh I: Component Separation Techniques
By Samuel W. Ross, MD, MPH; B. Todd Heniford, MD, FACS; Vedra A. Augenstein, MD, FACSPurchase PDF
Reconstruction of the Abdominal Wall With Mesh I: Component Separation TechniquesPurchase PDF
Truly complex hernias which are multiply recurrent, have active infections, loss of domain, presence of stomas, require component separation or panniculectomy, and/or have other exacerbating factors, are truly challenging to manage operatively, and the multidisciplinary operations to repair them have become known collectively as abdominal wall reconstruction (AWR). Component separation techniques and panniculectomy, to name a few, have become commonly used techniques for operative management for complex hernias. Herein, we describe the history and technical aspects of component separation, panniculectomy and other adjunct techniques in abdominal wall reconstruction. In particular, a focus on patient specific clinical outcomes such as hernia recurrence, wound complications, and quality of life has been made in regards to use and types of component separation. Our goal is to provide a comprehensive review of the state of the literature and our recommendations for AWR, for the Plastic, General, and Hernia surgeon alike.
This review contains 7 figures, 1 video, 1 table, and 79 references.
Keywords: ventral hernia repair, incisional hernia, abdominal wall reconstruction. component separation, transversus abdominis release (TAR), surgical site infection, advances in hernia repair, robotic hernia repair, robotic component separation, botulinum toxin
Reconstruction of the Abdominal Wall With Mesh II: Ventral Hernia Repair
By Samuel W. Ross, MD, MPH; B. Todd Heniford, MD, FACS; Vedra A. Augenstein, MD, FACSPurchase PDF
Reconstruction of the Abdominal Wall With Mesh II: Ventral Hernia RepairPurchase PDF
Incisional and Ventral hernia repair (VHR) is one of the most common surgical procedures in the world, and over the last two decades this field has enjoyed exponentially advances thanks to improvements in operative technique and biomechanical science. Truly complex hernias which are multiply recurrent, have active infections, loss of domain, presence of stomas, require component separation or panniculectomy, or have other exacerbating factors are truly challenging to manage operatively, and the multidisciplinary operations to repair them have become known collectively as abdominal wall reconstruction (AWR). Herein, we describe the surgical history of AWR, the current state of surgical techniques and mesh science, as well as novel areas for advancement of the field in the future. In particular, a focus on patient specific clinical outcomes such as hernia recurrence, wound complications, and quality of life has been made with regards to mesh position and selection. Our goal is to provide a comprehensive review of the state of the literature and our recommendations for AWR, for the Plastic, General, and Hernia surgeon alike.
This review contains 7 figures, 3 tables, and 79 references.
Keywords: ventral hernia repair, incisional hernia, abdominal wall reconstruction, mesh, pre-peritoneal hernia repair, pre-operative optimization, clinical outcomes, mesh position, surgical site infection, robotic hernia repair
Treatment of Empyema/bronchopleural Fistula
By Joseph A. Ricci, MD; Dennis P Orgill, MD, PhDPurchase PDF
Treatment of Empyema/bronchopleural FistulaPurchase PDF
Thoracic reconstruction represents one of the most challenging situations for a reconstructive surgeon. The resection of chest wall or pulmonary tumors allows for the development of a wide variety of complex wounds, many with significant dead spaces. Additionally, empyema and bronchopleural fistulas, while uncommon, represent potentially life threatening complications. The combination of new technology such as advanced biomaterials, advanced wound care modalities, and vascularized free tissue transfer have allowed these complex problems to be treated with low morbidity and mortality. The complexity of these operations requires a team approach including a cardiac or thoracic surgeon, a plastic surgeon, and intensive care specialists to provide advanced life support measures in the postoperative period. Closure and decontamination of these wounds can be achieved by following these principles: removal of infected necrotic tissue and foreign material via thorough debridement; repair of bronchopleural fistulas with muscle flaps; and minimization of any residual dead space with a combination of flaps and thoracoplasty, as needed.
This review contains 18 figures, 3 tables, and 31 references.
Keywords: bronchopleural fistula, chest wall reconstruction, intrathoracic dead-space, latissimus dorsi flap, muscle flaps, omental flap, pectoralis major flap, rectus abdominus flap
Chest Wall Reconstruction Following Tumor
By Farooq Shahzad, MBBS, FACS, FAAP; Evan Matros, MD, MMSc, FACSPurchase PDF
Chest Wall Reconstruction Following TumorPurchase PDF
Plastic surgeons are typically called upon to reconstruct the chest wall in four situations: oncologic resection, infections, trauma and osteoradionecrosis. In this chapter we will discuss post-oncologic reconstruction. Chest wall reconstruction following tumor resection is typically performed at the same setting as the ablative surgery; this results in quicker patient recovery and overall better outcomes. The reconstruction should be planned with the ablative surgeon so that an assessment can be made of the extent of resection and available donor sites for reconstruction. The major components of reconstruction are 1) skeletal support and 2) soft tissue coverage. Skeletal support is indicated if the defect is >5 cm, 4 or more ribs are removed or more than 2/3rd of the sternum is resected. Prosthetic mesh is most commonly used. Soft tissue reconstruction is performed with regional pedicled flaps in the vast majority of cases. Free flaps are used when regional flaps are not sufficient (large defects) or not available.
This review contains 11 figures, 3 tables, and 49 references.
Keywords: chest wall, tumor, skeletal reconstruction, soft tissue reconstruction, mesh, acellular dermal matrix, titanium osteosynthesis systems, resorbable plates, pedicled flaps, free flaps
Management of Pressure Injuries
By J. Michael Smith, MD; Kristen A. Aliano Messina, MD; Stefanos Boukovalas, MD; William B. Norbury, MD; Linda G. Phillips, MDPurchase PDF
Management of Pressure InjuriesPurchase PDF
Pressure injuries are a significant clinical challenge that incurs substantial morbidity for patients and cost for healthcare systems. These wounds often develop in the context of prolonged immobility and chronic disease. In this review, the authors outline fundamentals of pressure injury pathophysiology, important considerations in patient assessment, and a basic overview of the medical and surgical management of these complex patients. Additionally, a brief overview of innovative technologies on the horizon in the prevention, detection, and treatment of pressure injuries is presented. This chapter aims to provide baseline knowledge to enable the reader to function as an effective member of the multi-disciplinary team that cares for pressure injury patients.
This review contains 2 figures, 5 tables, and 31 references.
Keywords: pressure injury, pressure sore, chronic wounds, patient assessment, wound care, wound healing, surgical management, stem cells, prevention, medicine, plastic surgery
Treatment of Sternal Wound Infections
By Dennis P Orgill, MD, PhDPurchase PDF
Treatment of Sternal Wound InfectionsPurchase PDF
Sternal wound complications are a serious consequence of cardiac surgery. The use of muscle and/or omental flaps has been particularly important to treat these complications. The pectoralis major muscle is the most commonly used muscle to treat these infections. The greater omentum provides a potential rich source of vascularized tissue. Innovation in sternal union techniques provide surgeons with options to further prevent these complications in high risk patients. These complications remain with substantial morbidity and mortality and a multidisciplinary approach can minimize complications and reduce time in the hospital.
This review contains 4 figures, 2 tables, and 20 references.
Key words: sternum, wound, infection, mediastinitis, pectoralis major, omentum, sternal plates, sternal rewiring
- Head and Neck Reconstruction
Reconstructive Approaches to Nasal Defects
By Ravi K Garg, MD; Michael L. Bentz, MD, FAAP, FACSPurchase PDF
Reconstructive Approaches to Nasal DefectsPurchase PDF
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
Hypopharyngeal, Esophageal, and Neck Reconstruction
By Steven B Chinn, MD MPH; Peirong Yu, MDPurchase PDF
Hypopharyngeal, Esophageal, and Neck ReconstructionPurchase PDF
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
Head and Neck Melanoma: an Overview
By Samuel Kim, MD; Deepak Narayan, MDPurchase PDF
Head and Neck Melanoma: an OverviewPurchase PDF
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
By Mario A Aycart, MD; Bohdan Pomahac, MDPurchase PDF
Facial TransplantationPurchase PDF
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
By William J. Rifkin, BA; Jesus Rodrigo Diaz-Siso, MD; Eduardo D. Rodriguez, MD, DDSPurchase PDF
Midface ReconstructionPurchase PDF
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
Calvarial and Scalp Reconstruction
By Matthew M Hanasono, MDPurchase PDF
Calvarial and Scalp ReconstructionPurchase PDF
Scalp reconstruction involves nearly the entire spectrum of reconstructive surgery, including skin grafting, local flaps, and microvascular free flaps. Additionally, tissue expansion can play important role in maximizing outcomes. In recent years, reconstructive algorithms specific to scalp reconstruction have been developed that consider not only the size of the defect, but the quality of local tissues. Many materials have been used for calvarial reconstruction and most modern alloplasts are as reliable as autologous bone, although each as its own advantages and disadvantages. Simultaneous scalp and calvarial reconstruction is now routinely performed. Remaining challenges include management of wound complications over alloplasts and of the infected cranial bone flap following neurosurgical procedures.
This review contains 15 figures, 5 tables, and 41 references.
Keywords: scalp, calvarium, cranioplasty, free flap, tissue expander, skin graft, bone graft, titanium mesh, methylmethacrylate, polyetheretherketone (PEEK)
Basal and Cutaneous Squamous Cell Carcinoma of the Head and Neck
By Patrick M. Mulvaney, MD; Jonathan Weiss, MD; Daihung Do, MDPurchase PDF
Basal and Cutaneous Squamous Cell Carcinoma of the Head and NeckPurchase PDF
Basal cell carcinoma (BCC) is the most commonly diagnosed skin cancer in the United States and are most frequently encountered on sun-exposed body sites including the head and neck. They can be difficult to distinguish from other common skin neoplasms making biopsy a necessity for diagnosis prior to treatment. These tumors grow contiguously, are locally destructive but rarely metastasize making them good candidates for local surgical removal or destruction. This chapter reviews BCC epidemiology, pathogenesis, diagnostic approach and management considerations. Advanced tumors and practical considerations for plastic surgeons caring for these patients are also covered in detail. Squamous cell carcinoma (SCC) is the second most common malignancy of the skin. Most cases can be directly attributed to ultraviolet radiation (UVR), usually due to chronic sun exposure. With early detection, squamous cell carcinoma can be successfully treated with limited morbidity and low risk of mortality. Surgical modalities, namely Mohs micrographic surgery or wide local excision, are the gold standard for most invasive SCC. Advanced or particularly aggressive tumors carry a significant risk of local recurrence, nodal metastasis, and mortality. These risks highlight the importance of early detection, and appropriate risk stratification to guide the most appropriate treatment.
This review contains 5 figures, 6 tables, and 63 references.
Keywords: nonmelanoma skin cancers (NMSC), keratinocyte carcinomas (KC), basal cell carcinomas (BCC), squamous cell carcinomas (SCC), ultraviolet radiation (UVR), verrucous carcinoma, electrodesiccation and curettage (ED&C), photodynamic therapy (PDT), sentinel lymph node biopsy (SLNB), Brigham and Womens’s (BWH) tumor staging system
Primary Repair of Soft Tissue Facial Trauma
By Michelle Seu, BA; Amir H. Dorafshar, MBChB; Fan Liang, MDPurchase PDF
Primary Repair of Soft Tissue Facial TraumaPurchase PDF
Craniofacial trauma can result in a wide variety of injuries that cause soft tissue injury of face. However, despite the enormous diversity in presentation of these injuries, they tend to follow certain patterns. Most facial injuries are either contusions, abrasions, lacerations, or avulsions. The extent of injury and approach to repair can be further assessed by the size, depth, and number of facial subunits involved. A plastic surgeon in the setting of acute craniofacial trauma, armed with certain principles of facial anatomy and primary repair methods, can drastically restore function and cosmesis to the face, while also mitigating the chance of future deformity and functional deficit.
This review contains 3 figures and 26 references
Keywords: facial trauma, craniofacial surgery, primary repair, facial soft tissue defects, soft tissue, facial injury, plastic surgery, facial lacerations, facial avulsions
Reconstruction of the Orbit
By Imran Ratanshi, MD, MSc, FRCSC; Dennis C. Nguyen, MD; Michael J. Yaremchuk, MD, FACSPurchase PDF
Reconstruction of the OrbitPurchase PDF
Orbital defects require careful consideration due to the need to protect globe position and visual function. The orbit’s unique geometry requires working within a confined space. When indicated, orbital rim fractures or segmental defects can be reconstructed using low-profile, titanium mini-plates. Multiple implant options are available to support the globe when defects involve the orbital floor or medial wall. These materials should be able to contour to match the concavity of the orbit, thereby avoiding changes in orbital volume. For complex defects, virtual surgical planning strategies, including intra-operative navigation or the use of anatomic models for pre-operative plate bending or cutting guides for secondary osteotomies, can improve precision and reduce operative time. This chapter will describe operative indications and practical management options for orbital defects.
This review contains 7 figures, 1 video, 2 tables, and 38 references.
Keywords: orbit anatomy, periorbital trauma, orbital reconstruction, craniofacial imaging, alloplastic implant, mini plate, surgical approach, virtual surgical planning
By Branko Bojovic, MD, FACS; Martin Buta, MD, MBAPurchase PDF
Facial FracturesPurchase PDF
The understanding and management of craniofacial fractures have evolved through remarkable innovations in high-resolution imaging, surgical and fixation techniques, endoscopy, biomaterials and implants, bone grafting, new and refined classification frameworks, and algorithms for intervention. The concept of facial buttresses first described forty years ago now serves as a guide to reconstruction of the underlying skeleton to re-establish the height, width, and projection of the face. With the advent of 3D computed tomography and intraoperative imaging, surgeons have expanded the armamentarium for surgical planning and navigation, especially beneficial for accurate repair in complex cases. All of these advances have improved patient outcomes and raised expectations for functionally and aesthetically acceptable results. A brief overview of the assessment and management of facial fractures is presented.
This review contains 1 figure, 4 tables, and 43 references.
Key words: facial fracture, facial trauma, plastic surgery, orbital, maxillofacial, injury, Le Fort, malocclusion, skeletal buttress
- Congenital Anomalies of the Head and Neck
By Javier A Couto, MD; Arin K Greene, MD, MMScPurchase PDF
Vascular AnomaliesPurchase PDF
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
Distraction Osteogenesis in Plastic Surgery
By Elizabeth G Zellner, MD; Derek M Steinbacher, DMD, MD, FACSPurchase PDF
Distraction Osteogenesis in Plastic SurgeryPurchase PDF
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.
By Oksana A Jackson, MD; Alison E Kaye, MD; David W Low, MDPurchase PDF
Cleft PalatePurchase PDF
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
By Howard D Wang, MD; Robin Yang, MD, DDS; Joseph Lopez, MD, MBA; Edward W Swanson, MD; Amy Quan, MPH; Anand R Kumar, MDPurchase PDF
Orthognathic SurgeryPurchase PDF
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
Management of Speech and Swallowing Disorders in Children With Oral Clefts
By Ravi K. Garg, MD; Delora L Mount, MDPurchase PDF
Management of Speech and Swallowing Disorders in Children With Oral CleftsPurchase PDF
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
Craniofacial Syndromes Part I: Craniofacial Growth and Development, Craniosynostosis Syndromes, Craniofacial Microsomia, and Craniofacial Dysostoses
By Francesca Saldanha, MBBChir; Cory M. Resnick, MD, DMD; Carolyn R. Rogers-Vizena, MDPurchase PDF
Craniofacial Syndromes Part I: Craniofacial Growth and Development, Craniosynostosis Syndromes, Craniofacial Microsomia, and Craniofacial DysostosesPurchase PDF
Craniofacial syndromes are a diverse group of congenital disorders primarily affecting structures of the head and face. Recent genetic advances have improved our ability to diagnosis specific syndromes, understand the molecular basis for abnormal embryogenesis, and anticipate future treatment needs. This is the first of a two-part series exploring the most common craniofacial disorders. This article will provide the embryologic and developmental foundation necessary to understand congenital craniofacial pathology. Clinical characteristics and molecular genetics needed to make an accurate diagnosis and formulate a treatment plan will be detailed for craniosynostosis syndromes, craniofacial microsomia, and craniofacial dysostoses.
This review contains 13 figures, 4 tables, and 42 references.
Keywords: craniofacial embryology, craniofacial growth, craniosynostosis, Apert syndrome, Crouzon syndrome, Pfieffer syndrome, craniofacial microsomia, hemifacial microsomia, Treacher Collins syndrome, Nager syndrome
Craniofacial Syndromes Part II: Atypical Facial Clefts, Romberg Syndrome, Moebius Syndrome, Fibrous Dysplasia, and Neurofibromatosis
By Francesca Saldanha, MBBChir; Cory M. Resnick, MD, DMD; Carolyn R. Rogers-Vizena, MDPurchase PDF
Craniofacial Syndromes Part II: Atypical Facial Clefts, Romberg Syndrome, Moebius Syndrome, Fibrous Dysplasia, and NeurofibromatosisPurchase PDF
This final article of the two-part craniofacial series continues to provide the embryologic and developmental foundations necessary to understand congenital craniofacial pathology. Clinical characteristics and molecular genetics needed to make an accurate diagnosis and formulate a treatment plan will be detailed for atypical craniofacial clefts, Moebius Syndrome, Fibrous Dysplasia, Progressive Hemifacial Atrophy (Parry-Romberg syndrome) and Neurofibromatosis. Details of the operations applied in treatment of these disorders are discussed in separate Scientific American: Plastic Surgery (SAPS) articles as referenced.
This review contains 3 tables, and 10 figures, and 42 references.
Keywords: craniofacial, Tessier cleft, atypical facial cleft, Romberg syndrome, Parry-Romberg syndrome, Moebius syndrome, fibrous dysplasia, McCune Albright syndrome, neurofibromatosis
Craniosynostosis Part I: Pathophysiology and Patient Evaluation
By Jonathan Y. Lee, MD,MPH; Jesse A. Goldstein, MDPurchase PDF
Craniosynostosis Part I: Pathophysiology and Patient EvaluationPurchase PDF
Craniosynostosis is the premature fusion and obliteration of one or more cranial sutures. As a result, cranial growth can only occur parallel to the involved suture(s) resulting in predictable head shape morphologies. More importantly, the restricted cranial growth can also have a deleterious effect on the growing brain with increased intracranial pressures leading to abnormal neurocognitive development, blindness, and death. Craniosynostosis can either be syndromic or non-syndromic; and therefore, patient evaluation should be performed in a multi-disciplinary team setting for comprehensive care. Physical exam focuses on head shape morphology, associated anomalies, and signs of intracranial pressure. Imaging with 3D CT is gold standard at confirming diagnosis and extent of suture involvement. Early diagnosis is key for planning optimal intervention.
This review contains 14 figures, 4 tables and, 42 references.
Keywords: craniosynostosis, virchow’s law, plagiocephaly, trigonocephaly, scaphocephaly, brachycephaly, Apert Syndrome, Crouzon Syndrome, Pfeiffer Syndrome, intracranial pressure
By Raymond Tse, MD, FRCSCPurchase PDF
Cleft LipPurchase PDF
Cleft lip is one of the most common congenital anomalies that present to plastic surgeons. Care involves a multidisciplinary approach to address both aesthetic and functional needs. This review covers embryology, epidemiology, classification, and anatomy. It also provides a more in-depth description of treatment for unilateral, bilateral, and minor form clefts. Given the spectrum of presentation and the multiple tissue types involved, the general principles of reconstructive surgery are used as the framework for this review.
This review contains 16 figures, 3 tables, and 119 references.
Keywords: cheiloplasty, cleft lip, Fisher repair, microform cleft lip, Millard repair, orbicularis muscle, primary rhinoplasty, septoplasty, Tennison-Randall repair
Microtia and Ear Reconstruction
By Tal Kaufman-Goldberg, MD; Ingrid M. Ganske, MD, MPA; Carolyn R. Rogers-Vizena, MDPurchase PDF
Microtia and Ear ReconstructionPurchase PDF
Microtia is a congenital anomaly where the ear is smaller than normal and often missing its usual architecture. It is frequently accompanied by conductive hearing loss. Severity of microtia is highly variable. It can be an isolated anomaly, associated with other findings, or part of a syndrome. A coordinated approach is warranted to manage both aesthetic and functional concerns. Hearing rehabilitation options include bone conducting hearing aids that can be implanted or worn with a headband, and construction of the auditory canal for suitable candidates. Three treatment options for auricular construction should be considered. First, autologous construction that involves costal cartilage harvest, framework creation and implantation, lobule transposition, tragal and conchal construction, and ear elevation. Brent’s and Nagata’s methods are described, however various modifications exist. Second, alloplastic construction, as pioneered by Reinisch, consisting of a porous polyethylene framework covered by a temporoparietal facia flap, local flaps and skin grafts. Third, auricular prosthesis, mainly those retained with osseointegrated implants, that is an alternative to plastic surgery and suitable for certain microtia patients. Options are reviewed along with their advantages and disadvantages.
This review contains 5 tables, 10 figures, and 50 references
Key Words: microtia, anotia, ear construction, auricle construction, autologous ear construction, alloplastic ear construction, ear prosthesis, hearing rehabilitation
Head and Neck Tumors in Children
By Jason W. Yu, DMD, MD; Joseph Lopez, MD, MBA; Salim Afshar, DMD, MDPurchase PDF
Head and Neck Tumors in ChildrenPurchase PDF
The following chapter will provide a broad overview of the most common osseous lesions a surgeon will encounter when a pediatric patient presents with a bone-like head and neck tumor. The selected topics discussed below will be benign and malignant odontogenic cysts and tumors, and non-odontogenic benign (giant cell tumors, fibrous dysplasia, and juvenile ossifying fibroma) and malignant (osteosarcoma and ewing sarcoma) osseous tumors.
This chapter has 4 figures, 3 tables, and 40 references
Key Words: odontogenic cyst, non-odontogenic cysts, odontogenic tumors, giant cell tumor, fibrous dysplasia, juvenile ossifying fibroma, osteosarcoma, ewing sarcoma
Head and Neck Tumors in Children: Part II
By Jason W. Yu, DMD, MD; Joseph Lopez, MD, MBA; Salim Afshar, DMD, MDPurchase PDF
Head and Neck Tumors in Children: Part IIPurchase PDF
The following chapter will focus on common soft tissue lesions one would encounter as pediatric head and neck tumors. The selected topics covered will be cholesteatoma, craniopharyngioma, encephalocele, teratomas, dermoid cysts and pilomatrixoma. Salivary gland tumors discussed are pleomorphic adenoma, mucoepidermoid carcinoma, adenoid cystic carcinoma and acinic cell carcinoma. Vascular anomalies are covered in another section.
Keywords: cholesteatoma, craniopharyngioma, encephalocele, teratomas, dermoid cysts, neuroblastoma, pilomatrixoma, thyroglossal duct cysts, salivary gland tumors
- Cosmetic Surgery
Minimally Invasive Approaches to Forehead Rejuvenation
By Dhivya R Srinivasa, MD; Paul S Cederna, MDPurchase PDF
Minimally Invasive Approaches to Forehead RejuvenationPurchase PDF
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.
By Tiffany N Ballard, MD; Robert H Gilman, MD, DMDPurchase PDF
Upper BlepharoplastyPurchase PDF
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
Hair Transplantation: Biochemical Basis and Surgical Treatment
By Richard J. Ehrlichman, MD, FACS; Allan J. Parungao, MD, FACSPurchase PDF
Hair Transplantation: Biochemical Basis and Surgical TreatmentPurchase PDF
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
Open Eyebrow Correction
By Jason Gardenier, MD; Daniel Driscoll, MDPurchase PDF
Open Eyebrow CorrectionPurchase PDF
The open brow lift is a powerful tool for facial rejuvenation of the upper third of the face which can address rhytids, upper eyelid hooding, and brow ptosis. With a history dating back over a hundred years, a variety of techniques have been described including coronal, pretrichial, mid-forehead, direct supraciliary, and transpalpebral brow lifts. These vary in terms of invasiveness and the ideal approach is determined by patient age, sex, symmetry, and anterior hairline characteristics. While endoscopic techniques became popular in the 1990s based on novelty, smaller incisions, less post-scar numbness, and a perception of less invasive nature, this technique’s popularity has diminished recently and less invasive open approaches have become more popular. Recent years have seen the numbers of all forms of brow lift become less common as neuromodulators, such as botulinum toxin, allow for chemical denervation of brow depressor muscles. This has become a truly non-invasive way to address minor forms of aging of the forehead and brow. However, for advanced cases, open brow lift remains a powerful technique which should remain in the arsenal of the plastic surgeon.
This review contains 3 figures, 2 tables, and 39 references.
Keywords: cosmetic surgery, facial plastic surgery, facial aging, brow ptosis, rhytids, facial nerve, supraorbital nerve, supratrochlear nerve
Adjuncts to Facial Rejuvenation
By Heather R. Faulkner, MD, MPH, FACSPurchase PDF
Adjuncts to Facial RejuvenationPurchase PDF
The preferred methods for facial rejuvenation have been changing over the past decade, with operative procedures on the decline and minimally invasive, office-based procedures on the rise. As a result, it is critical for plastic surgery practitioners to understand the intricacies of the use of neuromodulators and soft tissue fillers in this milieu. While these procedures are usually performed in an office, without general anesthesia, the risk of significant complications still exists. The knowledge of facial anatomy, techniques, and pitfalls is essential for achieving high quality, predictable, and reproducible results. Likewise, when a complication arises, prompt recognition and appropriate treatment is paramount. In this chapter, the history, purpose, technical guidelines, and complications of adjunctive techniques for facial rejuvenation are reviewed in detail.
This review contains 2 tables, and 52 references.
Keywords: facial rejuvenation, neuromodulator, soft tissue filler, botulinum toxin, dermal filler, aging face, facial rhytids, filler complications, glabellar lines, nasolabial fold
By Ginger Xu, MD; Paul Hwang, MD; Nargiz Seyidova, MD; Samuel J. Lin, MDPurchase PDF
Open RhinoplastyPurchase PDF
Rhinoplasty is often considered the black box of plastic surgery. This apprehension can be overcome by having a fine-tuned understanding of nasal anatomy, developing an appreciation for nasal aesthetics, and becoming well-versed in the array of surgical techniques available to address specific cosmetic and functional concerns. Technical care and finesse are required in this type of surgery, where even 1 mm of change can result in a profound difference. Nasal function must also be assessed and preserved during rhinoplasty. Aside from these technical points, it is equally important to accurately and thoroughly understand each patient’s goals and to communicate the realistic outcomes and limitations of what can be done through surgery.
Key words: open rhinoplasty, nasal anatomy, nasofacial analysis, rhinoplasty techniques, rhinoplasty preoperative evaluation, rhinoplasty postoperative management, lateral nasal osteotomies, nasal tip grafts, nasal tip suture techniques
This review contains 23 figures, 2 tables, and 43 references.
By Branko Bojovic, MD, FACS; Martin Buta, MD, MBAPurchase PDF
Lower BlepharoplastyPurchase PDF
This review provides an overview of lower eyelid blepharoplasty, with discussion focused on relevant anatomy, the effects of aging on the lower eyelid and lid/cheek junction, patient evaluation, the most common surgical techniques, complications from surgery, and outcomes assessment. Emphasis is placed on tailoring surgical approaches to the specific aesthetic and functional concerns for each patient.
Keywords: blepharoplasty, lower lid surgery, transconjunctival blepharoplasty, transcutaneous blepharoplasty, pseudoherniation, cosmetic surgery, surgery techniques, aesthetic surgery, tear trough deformity, orbital fat, eyelid laxity, canthoplasty
This review contains 6 figures, 2 tables, and 50 references.
Body Contouring of the Trunk
By Heather R. Faulkner, MD, MPH, FACSPurchase PDF
Body Contouring of the TrunkPurchase PDF
Body contouring is a term that encompasses both surgical and non-surgical (minimally invasive) procedures for improving the form of the body. There are a variety of reasons patients may seek out truncal body contouring, including massive weight loss and changes associated with childbirth and aging. Knowledge of the available treatment options and technologies is paramount to the ability to counsel patients accurately about suitability for surgery, expected outcomes, and recognition of complications. This review covers pre-operative patient assessment, techniques, and complications of surgical and non-surgical treatments for body contouring of the trunk (excluding abdominoplasty, which is covered in a separate chapter).
This review contains 4 figures, 2 tables, and 27 references.
Keywords: body contouring, trunk, liposuction, lower body lift, upper body lift, skin tightening, skin laxity, cryolipolysis, panniculectomy, focused ultrasound, radiofrequency.
- Surgery of the Breast
By Eric J. Culbertson, MD; William P. Adams Jr, MDPurchase PDF
Breast AugmentationPurchase PDF
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
Prosthetic-based Breast Reconstruction
By Jonathan Nguyen, MD; Justin Williams, MD; Albert Losken, MDPurchase PDF
Prosthetic-based Breast ReconstructionPurchase PDF
Prosthetic reconstruction is the most popular option for breast reconstruction after mastectomy. There are several different techniques, such as prepectoral versus subpectoral placement, and delayed versus immediate reconstruction, each with their own sets of risks and benefits. With the advent of improved implant technology, acellular dermal matrix, and fat grafting, prepectoral direct to implant has become an accepted and increasingly popular method of reconstruction, with similar to improved complication rates and outcomes as traditional staged tissue expander reconstruction. Prosthetic reconstruction has had some recent controversies, including breast implant associated anaplastic large cell lymphoma and breast implant illness, and many future studies are being directed towards these topics.
This review contains 5 figures, and 53 references.
Keywords: breast reconstruction, breast implant, acellular dermal matrix, prepectoral reconstruction, tissue expander, fat grafting, capsular contracture, immediate reconstruction, breast implant associated anaplastic large cell lymphoma, breast implant illness
Surgical Approaches to the Irradiated Breast
By Megan Fracol, MD; Neil Fine, MDPurchase PDF
Surgical Approaches to the Irradiated BreastPurchase PDF
The use of radiation therapy for treatment of breast cancer has steadily increased since the 1990s. Plastic surgeons must be prepared to reconstruct patients with prior lumpectomy and radiation now needing salvage mastectomy, as well as the growing number of patients who will go on to need post mastectomy radiation therapy. Operating in the irradiated field presents unique challenges, including but not limited to intra-operative difficulties such as friable vessels when performing autologous-based reconstruction and higher rates of post-operative complications when performing implant-based reconstruction. Reconstructed outcomes are often inferior to the non-irradiated patient and as such the plastic surgeon should be prepared to perform further revision as necessary. This chapter will review indications for radiation therapy, both autologous- and implant-based approaches to reconstructing the irradiated breast and how to manage post-operative complications.
This review contains 3 figures, 5 tables, and 75 references.
Keywords: radiation, breast irradiation, breast reconstruction, radiation therapy, autologous reconstruction, implant-based reconstruction, revisionary breast surgery, complications
Free Flap-based Breast Reconstruction
By Adrian McArdle, MB, BCh, MD, FEBOPRAS, FRCSI; Joan E. Lipa, MSc, MD, FRCSC, FACSPurchase PDF
Free Flap-based Breast ReconstructionPurchase PDF
Breast cancer is one of the most common cancers worldwide affecting one in eight women. Surgery continues to be the mainstay of treatment, and mastectomy is performed for treatment and prophylaxis of breast malignancies. Autologous microvascular tissue transfer is frequently an option for breast reconstruction. In appropriate patients, microsurgical breast reconstruction is a safe procedure with low donor site morbidities and excellent aesthetic results. The lower abdomen, thigh, and gluteal regions are the main source of free flaps frequently used in breast reconstruction.
This review contains 10 figures, 2 tables, and 54 references
Keywords: breast cancer, breast reconstruction, breast surgery, microsurgery, autologous tissue transfer, free flap, deep inferior epigastric artery perforator flap (DIEP free flap), gracilis myocutaneous flap, gluteal artery perforator flap
By Aska Arnautovic, MD; Justin M. Broyles, MDPurchase PDF
Mastopexy and mastopexy-augmentation are commonly performed surgeries to lift ptotic breasts while improving breast shape and volume. Factors that cause breast ptosis include aging, hormonal changes, and weight loss. Common surgical approaches for mastopexy utilize the periareolar, vertical, and wise techniques. All of these techniques incorporate parenchymal rearrangement in addition to skin envelope resection in order to achieve the patient’s aesthetic goals. A plastic surgeon should carefully select the appropriate mastopexy technique based on a patient’s preoperative grade of ptosis, breast shape/volume, and aesthetic goals. Many of these mastopexy techniques can be combined with implant augmentation, either as a single or two-stage procedure in appropriate patients with volume concerns. Revisions tend to be more common after implant-augmentations and may be necessary based on patient concerns and surgeon discretion.
This review contains 5 figures, 5 tables, and 14 references
Keywords: mastopexy, mastopexy-augmentation, breast lift, breast ptosis, vertical mastopexy, periareolar mastopexy, wise pattern mastopexy, breast surgery
Secondary Revision of Breast Augmentation (capsular Contracture)
By J. Michael Smith, MD; Justin M. Broyles, MDPurchase PDF
Secondary Revision of Breast Augmentation (capsular Contracture)Purchase PDF
Revisionary surgery to correct problems following primary breast augmentation is a potentially complex clinical issue. Scarring, compromised vascularity, and other anatomical changes resulting from prior surgery increase both the operative difficulty and risk of post-operative complications. In this review, the authors outline the etiology and management of common problems that motivate patients to seek secondary breast augmentation; including capsular contracture, malposition, ptosis, rippling, and asymmetry. It is the aim of this chapter to provide the reader with a foundational understanding of the tools and techniques available to treat affected patients in order to maximize the probability of future success.
This review contains 3 figures, 6 tables, 31 references
Keywords: breast augmentation, breast revision, capsular contracture, malposition, ptosis, rippling, acellular dermal matrix, revision augmentation
Gynecomastia and Congenital Anomalies of the Breast
By J. Michael Smith, MD; Justin M. Broyles, MDPurchase PDF
Gynecomastia and Congenital Anomalies of the BreastPurchase PDF
Breast and chest wall appearance is an important component of an individual’s body image that can have a profound impact on their psychological well-being. Given the inherent complexity of breast embryogenesis, multiple anomalies exist that differ with respect to their clinical management and reconstructive approach. In this review, the authors outline fundamentals of breast embryology, pathophysiology of common congenital breast and chest wall anomalies, and potential reconstructive solutions. It is the aim of this chapter to provide readers with a broad yet concise overview of the spectrum of congenital breast and chess wall disorders to aid in the proper diagnosis and management of affected patients.
This review contains 7 tables, and 4 figures, and 31 references.
Keywords: breast embryology, pediatric breast reconstruction, gynecomastia, juvenile hypertrophy, polythelia, athelia, Poland syndrome, congenital breast
By Shailesh Agarwal, M.D.; Catherine WuPurchase PDF
Lympedema TherapiesPurchase PDF
Secondary lymphedema refers to a condition in which the affected extremity develops progressive hypertrophy due to lymphatic fluid retention. Worldwide, secondary lymphedema is most often associated with parasitic infection; within the United States, secondary lymphedema is most often caused by surgical disruption of the lymphatic drainage basins due to cancer surgery and/or radiation. For patients with lymphedema secondary to parasitic infection, treatment of the offending infectious organism (Wuchereria bancroftii) is critical. For patients with surgical disruption of the lymphatic drainage basin(s), patients are first managed non-operatively with compression and manual lymphatic drainage massage. Over the past decade, surgical techniques have been developed and implemented to improve lymphatic drainage for patients with post-surgical secondary lymphedema. These procedures, including lymphovenous bypass or vascularized lymph node transfer, are aimed at reconstituting lymphatic drainage and reducing lymphatic retention to alleviate early lymphedema. An appreciation of the underlying physiology responsible for secondary lymphedema, and diagnosis and management is required to provide timely and appropriate care for these patients.
This review contains 2 tables, 4 figures, and 32 references
Keywords: lymphedema, lymphedema treatment, secondary lymphedema, complete decongestive therapy, lymphovenous bypass, vascularized lymph node transplantation, debulking surgery, ICG lymphangiography, lymphedema staging
- Surgery of the Lower Extremity
Lower Extremity Reconstruction Following Tumor, Burns and Infections
By Dennis P Orgill, MD, PhDPurchase PDF
Lower Extremity Reconstruction Following Tumor, Burns and InfectionsPurchase PDF
Advances in plastic surgery have allowed for limb salvage in most cases of severe infection or tumor. This often involves moving adjacent or distant vascularized soft tissue into the area. Traditionally, surgeons have used the "Reconstructive Ladder" as a paradigm to consider various options to treat complex wounds. Common flaps in the lower extremity will be reviewed as well as case examples to illustrate the principles of reconstruction. New technologies such as dermal scaffolds, Negative Pressure Wound Therapy and Advanced biologics have all changed how we manage these conditions. Advances in the microanatomy of skin has allowed surgeons to design a wide array of new flaps simplifying the extent of surgical innovation.
This review contains 6 figures, 2 tables, and 27 references.
Keywords:lower extremity, wound, infection, tumor, osteomyelitis, sarcoma, lower extremity trauma, amputation, limb salvage
Treatment of Diabetic Foot Infections
By Shimpo Aoki, MD, PhD; Lauren R Bayer, PA-C; Dennis P Orgill, MD, PhDPurchase PDF
Treatment of Diabetic Foot InfectionsPurchase PDF
Thirteen percent of diabetic patients will develop a foot ulcer, often associated with infection, vascular disease and biomechanical changes. Limb salvage offers the potential to restore function but does not correct the underlying metabolic disturbance. We review the surgical approach to diabetic foot infections including debridement, skin grafts, local flaps and a variety of new technologies. A comprehensive multidisciplinary approach is beneficial to optimize outcomes. The full range of reconstructive options available to plastic surgeons may be used in the treatment of diabetic foot ulcers.
This review has 5 figures, 2 tables, and 20 references.
Key words: Diabetic Foot Infection (DFI), Diabetic Foot Ulcer (DFU), Diabetes Mellitus (DM), wound care, foot infection, bacterial infection, surgical management, neuropathy, surgery of the lower extremity, deformities
- Wound Healing
By Luis J Borda, MD; Penelope J Kallis, BS; Jose A Jaller, MD; Robert S Kirsner, MD, PhDPurchase PDF
Dermatologic WoundsPurchase PDF
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.
Pathophysiology of the Diabetic Foot
By Paul J Kim, DPM, MSPurchase PDF
Pathophysiology of the Diabetic FootPurchase PDF
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
Wound Management and the Utility of Adjunctive Technologies in Diabetic Limb Salvage
By Tammer Elmarsafi, DPM, MBBCh; John S Steinberg, DPM, FACFASPurchase PDF
Wound Management and the Utility of Adjunctive Technologies in Diabetic Limb SalvagePurchase PDF
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
Treatment of Arterial Ulcers
By Vahram Ornekian, MD, MS, RPVI; David E Janhofer, BS; Cameron Akbari, MD, MBA, FACS; Karen K Evans, MDPurchase PDF
Treatment of Arterial UlcersPurchase PDF
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
Biomechanics of the Diabetic Foot
By Paul J Kim, DPM, MSPurchase PDF
Biomechanics of the Diabetic FootPurchase PDF
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
By Rei Ogawa, MD, PhD, FACS; Dennis P Orgill, MD, PhDPurchase PDF
Cutaneous ScarringPurchase PDF
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
Venous Stasis Disease
By Allyson R Alfonso, BS, BA; Daniel Cuzzone, MD; Ernest S Chiu, MD, FACSPurchase PDF
Venous Stasis DiseasePurchase PDF
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
Medical and Surgical Treatment of Vasculitic and Autoimmune Ulcers
By Jenna C. Bekeny, BA; Elizabeth G. Zolper, BS; Vikas S. Kotha, BS; Kenneth L. Fan, MD; Carol Deane Benedict Mitnick, MD; Karen K. Evans, MDPurchase PDF
Medical and Surgical Treatment of Vasculitic and Autoimmune UlcersPurchase PDF
Chronic wounds of autoimmune and vasculitic etiologies, collectively referred to as “atypical ulcers”, are complex and heterogeneous. Evidence for a standardized approach remains deficient. Diagnosis requires a thorough history, physical exam, and investigative studies including serologic tests and wound biopsies. Management must be multidisciplinary and tailored to the individual patient and the unique characteristics of their wound. Medical therapy to stabilize the underlying disease is the most important aspect of therapy. Surgical intervention is often not appropriate and even contraindicated in some scenarios such as pyoderma gangrenosum. When medical therapy and local wound care fail and surgical intervention is deemed appropriate, inflammation must first be controlled with medical intervention before surgical intervention can be considered.
This review contains 5 figures, 2 tables, and 26 references.
Keywords: ulcer, wound healing, autoimmune diseases, vasculitis, pyoderma gangrenosum, scleroderma, rheumatoid nodule, immunosuppressive agents, rheumatology, patient care team
Surgical Coverage of Diabetic Feet
By Jenna C. Bekeny, BA; Vikas S. Kotha, BS; Elizabeth G. Zolper, BS; Christopher J. Kennedy, DPM; Jonathan Day, MS; Kenneth L. Fan, MD; Christopher E. Attinger, MD; Karen K. Evans, MDPurchase PDF
Surgical Coverage of Diabetic FeetPurchase PDF
Historically, patients with chronic diabetic foot ulcers were managed with major lower extremity amputations such as below-knee amputations and above-knee amputations. With the advancement of microsurgical techniques, patients have been able to achieve limb salvage and reap the associated morbidity and mortality benefits. In order to ensure successful limb salvage, a patient’s biomechanic, diabetic, vascular, and infectious profiles need to be optimized. Serial debridement supplemented with antibiotics until negative deep tissue cultures is the gold standard for infection eradication. A surgeon needs to have a good understanding of patient and wound-specific anatomic considerations. Simpler techniques, such as primary closure, skin grafting, and Integra placement, may be used. In complex wounds, more involved reconstructive modalities, such as local flap or free tissue transfer, may be required. Coverage selection depends on an intimate understanding of the patient’s comorbidities, wound characteristics, and vascular status.
This review contains 7 figures, 2 tables, and 32 references.
Keywords: diabetic foot ulcer, chronic wound, nonhealing vasculopathic wound, local flap, free flap, free tissue transfer, abductor digiti minimi flap, abductor hallicus flap, flexor digitorum brevis flap
Wounds in Patients With Cancer
By Mark W. Clemens, MD; Brian J. Blumenauer, MD; Ashleigh M. Francis, MD; Jonathon B. Olenczak, MD; Jesse C. Selber, MD; Sahil K. Kapur, MDPurchase PDF
Wounds in Patients With CancerPurchase PDF
Reconstructive surgery plays an integral role in helping restore form and function in patients with complex oncologic wounds. The intricate process of wound healing can be adversely affected by exposure to chemotherapeutic and radiation therapies. Assessment of available donor tissue quality, previous radiation therapy, vascular status, and donor site morbidity are essential when determining the most appropriate reconstructive approach for definitive wound management. The timing of reconstruction in relation to chemotherapy or radiotherapy regimens influences wound healing. Additionally, the timing of reconstruction is important in order to avoid delaying additional adjuvant therapies. Optimizing nutritional status is critical for improved patient outcomes in the oncologic patient population. At times, palliative efforts by means of surgical debulking are required of a reconstructive surgeon as advanced cancers can leave patients with disfiguring, fungating masses.
This review contains 9 figures, and 44 references.
Keywords: wounds in cancer, wounds in the cancer patient, oncologic wounds, oncologic wound healing, oncologic wound management, wound complications, effect of chemotherapy on wound healing, effect of radiation therapy on wound healing, oncologic reconstruction
Management of the Burn Wound
By Nicole S. Gibran, MD, FACS; Jose P. Sterling, MD; David M. Heimbach, MD, FACSPurchase PDF
Management of the Burn WoundPurchase PDF
Current approaches to burn management are based on an understanding of the biology and physiology of human skin and the pathophysiology of the burn wound. The clinical evaluation and initial care of a burn wound is described and includes an assessment of burn depth, determining the need for escharatomy and daily burn wound care. Burns can be topical or surgical. Topical burn wounds require choice in the use of antibiotics. Considerations and techniques for surgical burn wound management are described and include early excision and grafting, wound excision, skin grafting, graft and donor-site dressings, postoperative wound care, biologic dressings and skin substitutes, allograft and xenograft skin, cultured epidermal autografts, and skin substitutes. Figures show the two distinct layers of the skin, various types of burns, and both fascial and tangential excision of burn wounds.
This review contains 12 figures, 11 tables, and 61 references.
Keywords: Burn wound, graft, partial-thickness, full-thickness, dermis, epidermis, sloughing, dressing
- Surgery of the Hand
Upper Extremity Compartment Syndrome
By Jacob M Kirsch, MD; Simon Lee, MD; Jeffrey N Lawton, MDPurchase PDF
Upper Extremity Compartment SyndromePurchase PDF
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
Reconstruction of the Thumb After Traumatic Tissue Loss
By James E Clune, MD; Neil F Jones, MDPurchase PDF
Reconstruction of the Thumb After Traumatic Tissue LossPurchase PDF
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 9 figures, 3 tables and 51 references.
Key words: Thumb; reconstruction, amputation, pollicization, toe transfer, metacarpal lengthening, webspace deepening
Common Congenital Hand Differences
By Francisco Soldado, MD, PhD; Scott Kozin, MDPurchase PDF
Common Congenital Hand DifferencesPurchase PDF
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
Vascular Disorders of the Hand
By Matthew Treiser, MD; Christian E Sampson, MDPurchase PDF
Vascular Disorders of the HandPurchase PDF
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
Tenosynovitis Disorders of the Hand and Wrist
By Michael Aversano, MD; Nader Paksima, DO, MPHPurchase PDF
Tenosynovitis Disorders of the Hand and WristPurchase PDF
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 10 figures, 1 table and 86 references.
Key words: corticosteroid injection, de Quervain disease, hand/wrist pain, tendonitis, tenosynovitis, trigger finger
Flexor Tendon Injuries
By Chao Long, AB; Lisa C Moody, MD; Paige M Fox, MD, PhD; James Chang, MDPurchase PDF
Flexor Tendon InjuriesPurchase PDF
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
Wrist Fractures and Dislocations
By Angelo B Lipira, MD; Rahul K Kasukurthi, MD; Jerry I Huang, MDPurchase PDF
Wrist Fractures and DislocationsPurchase PDF
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
Microsurgical Reconstruction of the Upper Extremity
By Nikolas H Kazmers, MD, MSE; Stephanie Thibaudeau, MD; Zvi Steinberger, MD; L. Scott Levin, MD, FACSPurchase PDF
Microsurgical Reconstruction of the Upper ExtremityPurchase PDF
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
By Issei Komatsu, MD; Thomas B Hughes Jr, MDPurchase PDF
Hand FracturesPurchase PDF
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
By Scott D Lifchez, MD, FACS; Colton McNichols, MDPurchase PDF
Hand InfectionsPurchase PDF
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
By Todd A. Theman, MD; Kodi Azari, MDPurchase PDF
Compression NeuropathiesPurchase PDF
Compression neuropathies result from entrapment at specific anatomic locations. They are a common clinical problem, particularly in the upper extremity, where a patient’s underlying medical conditions can affect the likelihood of symptoms. Early recognition from the clinical history and a detailed examination, including provocative maneuvers, combined with electrodiagnostic testing or imaging modalities is imperative to guide treatment and prevent permanent dysfunction.
This review contains 7 figures, 2 tables, and 45 references.
Keywords: carpal tunnel syndrome, cubital tunnel syndrome, radial tunnel syndrome, ulnar tunnel syndrome, pronator syndrome, anterior interosseous syndrome, entrapment neuropathy, electrodiagnostic studies
Osteoarthritis of the Interphalangeal and Metacarpophalagneal Joints of the Hand
By Andrew J. Straszewski, MD; Jennifer Moriatis Wolf, MDPurchase PDF
Osteoarthritis of the Interphalangeal and Metacarpophalagneal Joints of the HandPurchase PDF
Hand surgeons frequently treat osteoarthritis of the interphalangeal (IP) and metacarpophalangeal (MCP) joints. Age, female gender, occupation, genetics, biomechanics, obesity, and joint laxity have been implicated in the progression of disease. Physical examination and standard three-view imaging of the hand aid in initial work up. Many conservative treatments exist, including physical therapy, splinting, anti-inflammatories, and injection of corticosteroid or hyaluronic acid. With the failure of conservative therapies, surgical management is dictated by the particular joint in question. The distal interphalangeal (DIP) joints of fingers and IP joint of the thumb are more commonly treated by arthrodesis, whereas proximal interphalangeal (PIP) joints are treated with arthroplasty. Likewise, MCP joints of the fingers are typically managed with arthroplasty. The thumb MCP joint is more commonly fused.
This review contains 7 figures, 4 tables, and 54 references.
Keywords: hand osteoarthritis, interphalangeal joint, metacarpophalangeal joint, anatomy, arthroplasty, silicone, arthrodesis, biomechanics, outcomes
Osteoarthritis of the Thumb Basilar Joint
By Andrew J Straszewski, MD; Jennifer Moriatis Wolf, MDPurchase PDF
Osteoarthritis of the Thumb Basilar JointPurchase PDF
Osteoarthritis of the thumb basilar joint is a common pathology treated by hand surgeons, and this is the leading cause of degenerative pain in the hand. Multi-factorial etiologies, including occupational stresses, gender, hormone milieu, and altered biomechanics, may play roles in the development of thumb carpometacarpal (CMC) joint arthritis. Patients present with aching pain, synovitis, weakened pinch and grip, and in late disease, adduction deformity and web space contracture. Physical examination and plain radiography are the mainstay of diagnosis, with little utility for advanced imaging. A multitude of options exists for conservative treatment: physical therapy, splinting, anti-inflammatories, and injections. With the failure of conservative therapies, surgical management is dictated by disease severity and provider preference. The thumb CMC joint hosts a variety of treatment options that have evolved over time: arthroscopy, osteotomy, arthrodesis, trapeziectomy alone, or with combinations of ligament reconstruction and tendon interposition. No superiority has been shown amongst the many base of thumb treatment modalities, though trapeziectomy alone demonstrates a lower complication rate.
This review contains 5 tables, 3 figures, and 61 references.
Keywords: hand osteoarthritis, base of thumb, anatomy, arthroplasty, silicone, arthrodesis, tendon reconstruction, biomechanics, tendon interposition, outcomes
Extensor Tendon Repair and Reconstruction
By Kelly D. Ledbetter, MD; Jeffrey B. Friedrich, MD, MC, FACSPurchase PDF
Extensor Tendon Repair and ReconstructionPurchase PDF
The purpose of this chapter is to review the anatomy and function of extensor tendons, the physiology of tendon healing, and general principles regarding common acute and chronic extensor tendon injuries. Acute injuries are classified according to the modified Verdan system and the presenting symptoms, physical exam findings, and treatment strategies are discussed by zone of injury. Common chronic extensor tendon injuries are discussed as they relate to the dorsal wrist's division into six discrete fibro-osseous compartments. Lastly, this chapter reviews the role of operative vs non-operative management as well as the use of immobilization vs early protective motion in the post-operative setting.
This review contains 7 figures, 1 table and 37 references.
Keywords: extensor, tendon, repair, reconstruction, rehabilitation, tendonopathy, surgery, splint
By Christopher Crowe, MDPurchase PDF
The advent of microsurgery has profoundly impacted the field of hand surgery, providing a means for precise coaptation of vessel and nerve, consequently allowing salvage of amputated parts. Despite these technical advances, the overall goal of management following amputation remains the same – provide the most functional outcome for each patient’s individual occupational and vocational needs. Therefore, it is not only the surgeon’s task to competently perform a replantation when necessary, but also understand in which patients and injuries a revision amputation may ultimately provide a superior outcome. Candidacy for replantation should be resolved by way of a focused history, physical examination, radiographic imaging, and a thorough discussion regarding the need for rehabilitation and potential for secondary procedures. Ultimately, there are very few absolute indications or contraindications for replantation, and each case must be considered on an individual basis.
This review contains 3 figures, 4 tables, and 28 references.
Key words: amputation, upper extremity, hand, digit, salvage, replant, replantation, revascularization, surgery of the hand
- General Surgery for Integrated Program
Initial Management of Life-threatening Trauma
By Emily Cantrell, MD; Jay Doucet, MD, FACS, FRCSC, RDMSPurchase PDF
Initial Management of Life-threatening TraumaPurchase PDF
Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.
This review contains 12 figures, 8 tables and 63 references
Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey