44. | Principles of Surgery, Companion Handbook

Chapter 43 Plastic and Reconstructive Surgery

Principles of Surgery Companion Handbook

CHAPTER

43
PLASTIC AND RECONSTRUCTIVE SURGERY

Basic Principles
	Skin Incisions
	Wound Closure
	Skin Grafting
	Flaps
	Free Tissue Transfer
	Tissue Expansion
	Liposuction
Reconstructive Surgery
	Breast
	Chest and Abdominal Wall
	Lymphedema
	Lower Extremity Defects
Aesthetic Surgery
	Facial Aging
	Abdomen, Thighs, Buttocks, and Upper Arm
Head and Neck Surgery
	Congenital Deformities
	Acquired Deformities
	Facial Fractures
	Reconstruction after Tumor Excision

BASIC PRINCIPLES

Skin Incisions

Incisions should be planned parallel to the skin lines. Elliptical incisions have a long axis three to four times the length of the short axis to prevent standing cones at the ends of the incision.

Wound Closure

Wound preparation includes debridement of the skin edges and the use of noncrushing instruments. Excess tension produces a wide scar. Undermining and subcutaneous absorbable sutures help reduce wound tension. Early suture removal reduces scarring. Facial sutures should be removed at 3–5 days to prevent suture marks.

Skin Grafting

Split-thickness skin grafts include epidermis and a portion of the dermis. Full-thickness skin grafts include the epidermis and the entire dermis. “Take” of a skin graft requires an adequately vascularized recipient bed. Skin grafts will “take” on paratenon and periosteum but not bare tendon or bone.

Skin grafts may be stored for up to 21 days soaked in sterile saline at 4°C. Meshing of a skin graft allows an increased area to be covered, irregular contours to be covered more easily, and escape of fluid that would normally accumulate under the graft and could compromise graft survival. Grafts to the face and hands should not be meshed. Not meshing a graft will require fluid to be removed by syringe and needle as it accumulates under the graft.

Grafted areas must be kept immobilized, since motion may disrupt the graft. Grafts to the extremities require elevation of the extremity.

Grafts “take” by plasmatic imbibition (48 h), followed by capillary ingrowth (2–5 days). Wounds with greater than 10⁵ bacteria per gram of tissue will not support a graft.

Composite grafts contain several tissue layers, such as ear skin and cartilage grafted to the nose. “Take” usually is accomplished if no portion of the graft is more then 1 cm from the vascular bed.

Flaps

Random Flaps Z-plasty, advancement, rotation, transposition, and interpolation flaps are based on the dermal-subdermal vascular plexus and are used for covering adjacent defects.

Axial Flaps Forehead flaps, deltopectoral flaps, and omental flaps are examples of axial flaps. They are based on specific vessels within the flap. They are better vascularized and more reliable than random flaps.

Fasciocutaneous Flaps These include the underlying fascia as well as the subcutaneous tissues. A good vascular supply allows greater length to the flap.

Muscle or Myocutaneous Flaps These include a muscle with its blood supply and may include its overlying skin.

Free Tissue Transfer

Many myocutaneous and some fasciocutaneous flaps have a consistent vascular pedicle, which may be divided and reanastomosed to recipient vessels at a distant site.

Tissue Expansion

Tissue expanders are inflatable devices placed under the skin and subcutaneous tissue. The tissue expander is filled with sterile saline over a number of weeks. Once enough tissue is expanded, the tissue expander is removed, and the defect is closed with transposition of the expanded skin.

Liposuction

Through one or more small incisions, a metal cannula is inserted into the area of excess fat deposition. The cannula cuts the fat, which is then aspirated via a vacuum device attached to the cannula.

RECONSTRUCTIVE SURGERY

Breast

Macromastia This is an abnormal enlargement of the breast. Reduction is achieved with resection of the redundant breast tissue and nipple preservation by pedicle or full-thickness nipple-areola graft. Risks include nipple necrosis, decreased sensation of the nipple, and an inability to lactate or breast-feed.

Ptosis Ptosis occurs when the nipple has descended below the inframammary crease. Repair involves nipple repositioning with reduction or placement of implants depending on the cause of the ptosis.

Hypomastia Hypomastia is insufficient volume in one or both breasts. Augmentation is performed with a prosthesis placed in either the submuscular or subglandular position.

Reconstruction after Mastectomy This can be accomplished with tissue expanders and subsequent prosthesis or myocutaneous flap (e.g., latissimus dorsi or rectus abdominis). Repair may be immediate or delayed until after radiation therapy or chemotherapy. There is no known increased risk of recurrence or failure to identify recurrence after reconstruction. Reconstruction may be needed on the nonmastectomy breast to obtain symmetry.

Gynecomastia This is an enlargement of the male breast secondary to increased ductal tissue. The most common form is idiopathic and occurs in adolescence. Treatment in adolescence is expectant, since the process usually resolves spontaneously within 2 years. For excessive enlargement or enlargement of greater than 2 years' duration, excision through a circumareolar incision is the treatment of choice.

Chest and Abdominal Wall

Defects may be secondary to trauma, tumor resection, radiation necrosis, infection, or congenital abnormalities. Repair usually is accomplished with one of several myocutaneous flaps (e.g., latissimus dorsi or deltopectoral). Pressure sores often appear small externally and usually are located over a bony prominence. Their presence may indicate a more extensive involvement of underlying subcutaneous tissue, fascia, and muscle.

Lymphedema

This may be secondary to regional lymph node dissection or congenital malformation. Nonoperative treatment consists of elevation and compression. Surgical management (for those failing medical therapy) includes excision of involved tissue either under skin flaps or with split-thickness or full-thickness skin grafts. Microvascular lymphaticovenous anastomosis has inconsistent results.

Lower Extremity Defects

Small tissue defects, those less than 1 cm, can be expected to heal on their own. Venous stasis ulcers need treatment of venous disease before reepithelialization or split-thickness skin grafting. Large defects, such as compound tibial fractures with soft tissue injury, are best managed with fasciocutaneous, muscle, or musculocutaneous flaps. Local muscle transposition usually is the preferred treatment except for wounds in the distal third of the tibia, where free muscle transfer is used most often.

AESTHETIC SURGERY

Facial Aging

Rhytidectomy (Face Lift) This involves an incision in the hairline at the lateral aspect of the forehead, continued in front of the ear, inferior and then posterior to the lobe. The skin is undermined from the frontalis muscle to the platysma in order to free it from the underlying structures. The skin is then advanced toward the ear and secured to the fascia anterior to the ear. The redundant tissue is excised. Rhytidectomies may be performed more than once.

Dermabrasion This improves fine wrinkling.

Chemical Face Peel This tightens skin and flattens fine wrinkles.

Eyelid Bagging of the eyelids or ptosis can be corrected by blepharoplasty (excision of redundant lid skin and fat) and/or brow lift.

Nose Rhinoplasty, performed under local or general anesthesia, can be done with incisions hidden inside the nose to minimize visible scarring.

Abdomen, Thighs, Buttocks, and Upper Arm

Redundant skin secondary to aging or significant weight loss may be surgically excised; however, resulting scars are often fairly prominent.

HEAD AND NECK SURGERY

Congenital Deformities

Cleft Lip These deformities may be unilateral or bilateral and incomplete (skin bridge connecting the cleft and noncleft sides) or complete (no skin bridge). Repair usually is timed according to the “rule of tens”: at least 10 weeks of age, 10 lb, and a hemoglobin level of 10 g. Unilateral repairs are often done in one stage, whereas bilateral clefts may be done in one or two stages. Associated nasal deformities may be repaired at the same time or at a later date.

Cleft Palate This occurs when fusion of the two palatial processes is incomplete. Repair usually is performed by the age of 6–18 months. Late repair may affect speech development; early repair may affect facial growth.

Craniofacial Anomalies Craniosynostosis—Apert syndrome and Crouzon syndrome—involves premature closure of one or more cranial sutures and associated facial deformity. Repair involves separation and repositioning of the involved bone and the use of bone grafts, interosseous wiring, and miniplates for support.

Maxillomandibular Disproportion Abnormal size, shape, and position of the mandible or maxilla can result in malocclusion. Less severe disproportioning can be corrected with orthodontia. More severe disproportioning—micrognathia, retrognathia, and prognathia—requires surgical correction by splitting, advancing, or resecting a portion of the mandible depending on the specific deformity. Small chin not associated with any malpositioning can be treated with silicone prosthesis or sliding genioplasty to improve projection. Repair of severe maxillary deformities—hypoplasia or hyperplasia—involves surgical fracturing of the maxilla with repositioning.

Ear Deformities Microtia These are congenitally small, malformed ears; they are repaired in stages beginning at the age of 5–6 years. Rib cartilage is used for the structural framework.

Prominent Ears These are corrected by elevating and excising a portion of the skin from the posterior aspect of the ear and scoring the underlying cartilage, recreating the anthelix. Closure results in a more normal contour.

Hemangioma and Lymphangioma Capillary Hemangiomas These are abnormal collections of small vessels. They become prominent at 1–3 weeks of age, often increase in size over the first 6 months, and usually disappear spontaneously over the next several years. Surgical excision may be performed for compromised vision or respiration or for failure to resolve spontaneously.

Cystic Hygroma Most often this involves the head and neck. Swelling often accompanies upper respiratory infections and may compromise the airway. Should surgical excision be required, partial excision may be all that is possible in order to preserve local vital structures.

Acquired Deformities

Skull and Scalp Deformities Avulsions of the scalp may be closed by microvascular replantation, split-thickness skin grafting, or multiple scalp flaps transposed into the defect. Loss of scalp and calvarium requires early coverage to decrease the risk of infection. Transposition flaps can cover small defects. Free tissue transfer or split-thickness skin grafting may be necessary to cover larger areas of loss.

Eyelid and Eyebrow Reconstruction Loss of one-fourth or less of either lid can be closed directly. Larger defects in the upper lid are closed with composite tissue from the lower lid. Local flaps from a portion of the upper lid or the cheek can be used to reconstruct the lower lid. Loss of the hair-bearing eyebrow can be replaced using hair-bearing tissue from the scalp.

Eyelid Ptosis Moderate ptosis is managed by resection of a portion of the levator aponeurosis. Severe forms are treated by suspension of the eyelid by a portion of the frontalis muscle.

Nasal Reconstruction This is done after loss of part or all of the nose, as from skin cancer; the support framework is supplied by bone graft, and skin coverage is provided by nasolabial, forehead, or scalp flaps.

Lip Reconstruction Full-thickness lip defects usually are reconstructed with various local lip flaps.

Facial Palsy Lacerated or resected facial nerves should be repaired or grafted promptly. Long-standing palsy traditionally was treated with static suspension of the cheek and/or eyelid. Newer techniques include muscle transfers and nerve grafts.

Parotid Duct Laceration This may be repaired over a stent or can be tied off proximally.

Facial Fractures

Examination Examination proceeds from the upper to the lower face and includes an ophthalmologic examination, intraoral as well as extraoral examination of the mandible and maxilla, evaluation of dental occlusion, and assessment of midface stability by grasping the upper incisors and gently attempting to displace the structures anteriorly and posteriorly.

Radiographic Studies Fractures are diagnosed by visible fractures, blood in the sinuses, or subcutaneous air on computed tomographic (CT) scan and plain films.

Mandibular Fractures The mandible is often fractured in more than one place, and displacement is common secondary to the pull of the muscles of mastication. Treatment is early reduction and restoration of normal dental occlusion and firm immobilization. These may be managed by intermaxillary fixation or open reduction and internal fixation using plates and screws. Antibiotics should be given in open fractures.

Zygomatic Fractures These are often displaced. Significant deformities require mandatory open reduction and internal fixation and correction of orbital floor fracture.

Orbital Fractures “Blowout” fractures may trap the inferior rectus muscle and often are associated with double vision. Surgical repair involves returning of the herniated tissue to the orbit and reinforcing the orbital floor with alloplastic sheeting or bone graft.

Nasal Fractures Obvious deformities are corrected immediately. With nasal edema, reduction of the nasal fracture is delayed several days until the swelling subsides. Septal hematomas should be drained and the nose packed.

Maxillary Fractures These are classified as Le Fort I (transverse)—separation of the lower maxilla, hard palate, and pterygoid processes from the rest of the maxilla; Le Fort II (pyramidal) separation along the nasofrontal suture, floor of the orbit, zygomaticomaxillary sutures, and the pterygoid processes; and Le Fort III (craniofacial disjunction)—separation of the midface from the rest of the cranium by fracture through the zygomaticofrontal sutures, nasofrontal sutures, and the floor of the orbit. Treatment for Le Fort fractures is open reduction and internal fixation and intermaxillary fixation.

Reconstruction after Tumor Excision

Intraoral Defects Many can be managed with split-thickness skin grafting. Larger defects can be closed with forehead, deltopectoral, platysma, sternocleidomastoid, and pectoral flaps or free tissue transfers.

Bony Deficits These may be managed with bone grafts or composite bone and soft tissue grafts (e.g., fibula, scapula, and ilial crest).

Reconstruction of the Cervical Esophagus This can be achieved by numerous musculocutaneous flaps, gastric transposition, or intestinal interposition with microvascular anastomosis.

For a more detailed discussion, see Wood RJ, Jurkiewicz MJ: Plastic and Reconstructive Surgery, chap. 43 in Principles of Surgery, 7th ed.