Textbook PTTHTM 2022
Textbook PTTHTM 2022
Textbook PTTHTM 2022
and Reconstructive
Surgery
sachyhoc.com
Basic Principles and
New Perspectives
Michele Maruccia
Giuseppe Giudice
Editors
123
Textbook of Plastic and Reconstructive
Surgery
Michele Maruccia • Giuseppe Giudice
Editors
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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Foreword 1
It is with great pleasure and honor that I, as President of the Italian Society of
Plastic, Reconstructive and Aesthetic Surgery, introduce this new Textbook of
Plastic and Reconstructive Surgery, which joins most, if not all, Italian plastic
surgery names to provide the highest quality work.
As plastic surgeons we are always bound by the desire to perform the best
care for our patients and this philosophy surely inspired all authors in writing
their chapters. Many of the contributors are plastic surgery experts; however,
there is also a new span of young surgeons whose contributions are equally
outstanding, providing a new and contemporary input.
The Plastic Surgery School of Bari, with its old tradition in the South of
Italy, has trained an entire generation of plastic surgeons in the last 30 years
and has maintained its high standard in research and training. This book
offers different approaches and techniques to classical and newer clinical
problems.
We hope you enjoy this up-to-date Plastic and Reconstructive Surgery
book, witness of the growth and advancement of Italian plastic surgery in
Europe in the last decades.
Francesco D’Andrea
University of Naples Federico II
Naples, Italy
v
Foreword 2
Plastic surgery deals with the entire body by representing the scaffold all
surgeries are based on. There is a constant demand of comprehensive infor-
mation and instruction on plastic surgery. The aim of this book is to give
students, trainees, and young practitioners the opportunity to approach the
spectrum that is plastic surgery, providing a comprehensive and single-
volume textbook. The book is aimed at practicing plastic surgeons, residents,
medical students, and physician’s assistants to meet the need of intuitive, easy
reading and effective homing of concepts of interest. This text does not aim
to describe the entire body of plastic surgical knowledge, but it represents a
practical source of information and it delivers an attractive introduction to the
subject. Indications, anatomy, surgical techniques, and advantages and disad-
vantages of the discussed topics are mainly given by intuitive, readily avail-
able, and precise information to help a day-to-day learning. The chapters are
described in such an accessible arrangement to help each individual reader to
achieve a satisfactory plastic surgical knowledge. The high quality of this
book is provided by the authors which are consultant plastic surgeons, and
each adds exceptional value to the text. This core knowledge is a collection of
current thoughts gleaned from the wide experience of the authors. Evidence-
based advice from experts is fundamental to give information about typical
difficulties than can occur during the decision-making process. The splitting
of complex topics into simple notes makes the learning process easier to mas-
ter every subject successfully. This is the first Italian book edited in English
language. Each chapter represents the best combination of simplicity and
comprehensiveness where the answer the reader needs can be easily found.
We hope this attractive and comprehensible method will act as a stimulus to
plastic surgery approach for all surgeons who are involved in this area.
Giorgio De Santis
Azienda Ospedaliero-Universitaria Policlinico di Modena
Modena, Italy
vii
Preface
ix
x Preface
The book ends with a chapter dedicated to the role of the plastic surgeon
in the Covid-19 era. The pandemic has revolutionized the life of each one of
us, has given us time to reflect on many aspects, and has seen the rediscovery
of true and sincere values. The plastic surgeon has fought in the front lines
against Covid-19 and the academic world has also done so through numerous
scientific testimonies. This book was born in this era and wants to be a tool
that highlights the role of reconstructive and aesthetic plastic surgery, not
only in the biomedical world but also in modern society.
xi
xii Contents
15 Wounds���������������������������������������������������������������������������������������������� 241
Giovanni Papa, Stefano Bottosso, Vittorio Ramella,
and Zoran Marij Arnež
16 Upper Limb Trauma������������������������������������������������������������������������ 257
Bruno Battiston, Maddalena Bertolini, Paolo Titolo,
Francesco Giacalone, Giulia Colzani, and Davide Ciclamini
17 Lower Limb Trauma������������������������������������������������������������������������ 271
Mario Cherubino, Tommaso Baroni, and Luigi Valdatta
18 Burns: Classification and Treatment���������������������������������������������� 285
Elia Rossella, Maggio Giulio, and Maruccia Michele
thoát mạch
19 Extravasation������������������������������������������������������������������������������������ 303
Sara Carella and Maria Giuseppina Onesti
20 Radiodermatitis: Prevention and Treatment�������������������������������� 313
Diego Ribuffo, Federico Lo Torto, and Marco Marcasciano
pt hàm mặt
21 Maxillofacial Surgery���������������������������������������������������������������������� 323
Giuseppe Giudice and Erica Tedone Clemente
Index���������������������������������������������������������������������������������������������������������� 531
List of Videos
xv
Part I
Principles in Plastic Surgery
Anatomy and Physiology
of the Skin
1
Michelangelo Vestita, Pasquale Tedeschi,
and Domenico Bonamonte
1.Epidermis
2.Dermis
3.Arrector
pili muscle
4.Sebaceous
gland
6.Apocrine
gland
7.Hair follicle
5.Subcutaneous
fat
8.Vater-pacini
corpuscle
9.Eccrine gland
Fig. 1.1 Cross section of the skin and subcutaneous fat. (1) Epidermis, (2) dermis, (3) arrector pili muscle, (4) seba-
ceous gland, (5) subcutaneous fat, (6) apocrine gland, (7) hair follicle, (8) Vater–Pacini corpuscle, and (9) eccrine gland
Slow-cycling stem cells provide a reservoir for by the disappearance of cell organelles and the
epidermis regeneration. Sites rich in stem cells aggregation of all contents into a mixture of fila-
include the rete’s deepest portions, especially on ments and envelopes of amorphous cells. This
da lòng bàn tay
palmoplantar skin, and hair bulge. Stem cells can programmed maturation cycle resulting in cell
be characterized by their elevated β1-integrin death is called terminal differentiation.
expression and lack of markers of terminal dif- Within normal skin, an intercellular space
ferentiation. The basal cells divide and flatten and divides the plasma membranes of neighboring
their nuclei vanish as their progeny passes upward. cells. Electron microscopic histochemical studies
During keratinization, the keratinocyte goes have shown that this interspace contains lipids
through a synthetic phase first and then a degrad- and glyco buffer proteins. In this area, lamellar
ing process on its way to being a horn cell. In the granules appear, mainly at the interface between
synthetic phase, the keratinocyte accumulates the granular and cornified cell layers. Lamellar
intermediate filaments within its cytoplasm com- granules contribute to cohesiveness and imper-
posed of a fibrous protein, keratin, arranged in a meability in the skin. Glycolipids, for example,
coiled pattern of α-helicals [1, 2]. Such tonofila- ceramides, contribute to the function of a water
ments are formed into bundles that converge and barrier to the skin. Desmosomal adhesion
end at the plasma membrane, where they end up depends on cadherins including desmogleins and
in special attachment plates called desmosomes desmocollins, which are calcium-dependent pro-
[3]. The decaying keratinization process is marked teins [4].
1 Anatomy and Physiology of the Skin 5
3.Keratinocyte
4.Langerhans
12.Stratum cell
spinosum
tb giống thực bào
5.Melanocyte
tb hắc tố
6.Merkel cell
13.Stratum tb cảm thụ
basale 7.Tactile disc
8.Sensory
14.Dermis
neuron
niculus can be found the coiled secretory acinar where bacteria alter it and makes it odorous.
part of the eccrine sweat gland. The eccrine coil Apocrine release is mediated by the adrenergic
is located in the deep dermis, surrounded by an innervation and the circulation of adrenomedul-
extension of fat from the underlying panniculus, lary catecholamines.
in areas of skin such as the back that possess a Apocrine excretion is episodic while the
thick dermis. A sheet of smooth myoepithelial gland’s actual secretion is continuous.
cells surrounds an inner layer of epithelial cells, While sometimes present in an ectopic posi-
the secretory part of the gland. tion, the human body’s apocrine units are usually
There are two types of secretory cells: large, restricted to the following sites: axillae, areolae,
light, glycogen-rich cells and smaller, darker- anogenital area, external auditory canal (cerumi-
staining cells. It is thought that the pale, glycogen- nous glands), and eyelids. Apocrine glands do not
rich cells initiate sweat formation. The darker start working until puberty.
cells may function similar to dermal duct cells,
which actively reabsorb sodium, thus modifying
sweat from a basically isotonic to a hypotonic 1.4.3 Hair Follicles
solution as long as it reaches the surface of the
skin. The uppermost part of the hair follicle, stretching
By composition, sweat is similar to plasma, from its opening surface to the entrance of the
containing the same electrolytes but at a more sebaceous duct, is called the infundibular seg-
dilute concentration. Eccrine sweat units are ment, which resembles the surface epidermis.
present in nearly every skin site in humans. As a The isthmus is the part of the follicle between the
result of many factors, physiological sweat secre- sebaceous duct and the insertion of the muscle
tion occurs and is mediated by cholinergic inner- arrector pili (Fig. 1.1). Within this isthmic sec-
vation. Heat is a prime incentive for increased tion, the inner root sheath completely keratinizes
sweating, but other physiological factors, includ- and sheds. The lower section contains the folli-
ing emotional stress, are also important. cle’s lowermost part and the hair filament. The
inferior part goes through cycles of involution
and regeneration during life [9–11].
1.4.2 Apocrine Units The hair follicles sequentially grow in three
rows. The primary follicles are surrounded by
As outgrowths, apocrine units form not from the two secondary follicles. The density of piloseba-
surface epidermis but from the infundibular or ceous units declines during life, likely as the sec-
upper portion of the hair follicle (Fig. 1.1). The ondary follicles drop out.
duct’s straight excretory part, which opens into The actual hair shaft is formed by the matrix
the hair follicle’s infundibular section, is com- portion of the hair bulb, as well as an inner and an
posed of a double layer of cuboidal epithelial outer root sheath (Fig. 1.3). The sheaths form
cells. concentric cylindrical layers. The hair shaft and
The coiled secretory gland lies at the junction the inner root sheath move together as the hair
between the dermis and subcutaneous fat. It is grows upward until the isthmus level is shed by
filled by a single layer of cells, which range from the fully keratinized inner root sheath. The upper
columnar to cuboidal in shape. A layer of myo- two sections of the follicle (infundibulum and
epithelial cells surrounds that layer of cells. isthmus) are permanent; each new hair growth
Apocrine coils tend to be more dilated than process complete replaces the lower segment.
eccrine coils, and apocrine sweat stains tend to be The active growth phase, on the scalp, anagen,
darker red in H&E pieces, in contrast to light lasts about 3–5 years. Approximately 80–90% of
pink eccrine sweat. all scalp hairs are usually in the anagen process.
Apocrine secretion contains protein, carbohy- Scalp anagen hairs grow at about 0.37 mm/day.
drate, ammonia, lipid, and iron. Apocrine sweat Catagen, or involution, lasts 2 weeks or so. The
is odorless until it reaches the surface of the skin resting period of the telogen lasts for around 3–5
1 Anatomy and Physiology of the Skin 9
2.Cortex
3.Hair cuticle
4.Inner root
sheath
5.Outer root
sheath
months. Most body locations have a much shorter synthesize melanosomes and transfer them to the
anagen and much longer telogen, leading to short bulb matrix keratinocytes. Larger melanosomes
hairs that remain in place for long periods of time are present in black people’s hair; in white peo-
without growing longer. ple’s hair, melanosomes are smaller and are
aggregated within membrane-bound complexes.
Red hair is characterized by melanosomal sphe-
Key Point ricity. The hair graying results from a reduced
Human hair growth is cyclic, but each folli- number of melanocytes, which produces less
cle operates as an individual entity. As a melanosomes. Repetitive oxidative stress induces
matter of fact, humans do not shed hair syn- hair follicle melanocyte apoptosis, which results
chronously. Each hair follicle goes through in normal hair graying.
sporadic stages of operation and quiescence. Stem cells in hair follicles are found inside the
Synchronous anagen or telogen termination outer root sheath, at the lowest permanent part of
results in telogen effluvium. the follicle. These cells cycle more slowly than
other cells and are capable of migrating as well as
differentiating into various lineages, such as
outer and inner root sheaths, hair shaft, sebo-
Tips and Tricks cytes, and interfollicular epidermis.
Telogen effluvium is most commonly the
product of early release from anagen, such
as that caused by weight loss, trauma, 1.4.4 Sebaceous Glands tuyến bã nhờn
febrile disease, or surgery.
Sebaceous glands emerge as an outgrowth from
the upper portion of the hair follicle (Fig. 1.1),
The color of hair depends on the degree of made of pale-staining cell lobules with abundant
melanization and distribution within the hair lipid droplets. Basaloid germinative cells are
shaft of melanosomes. Hair bulb melanocytes noted at the periphery of the lobules. Such cells
10 M. Vestita et al.
give rise to the lipid-filled pale cells, which are as in the dermis. Collagen accounts for 70% of
continually extruded into the infundibular por- dry skin weight. Fibroblasts synthesize the pro-
tion of the hair follicle through the short seba- collagen molecule, a helical structure of unique
ceous duct. polypeptide chains, which are then secreted by
Sebaceous glands on the face and scalp are the cell and assembled into fibrils of collagen.
found in greatest abundance, although they are Collagen is rich in hydroxyproline, hydroxyly-
distributed throughout all sites except palms and sine, and glycine amino acids. The main compo-
soles. nent of the dermis is collagen of type I. Type I
Lipids by sebaceous glands contribute to the collagen structure is uniform in width, with each
skin barrier function, and some have antimicro- fiber displaying characteristic cross-striations
bial properties. Antimicrobial lipids include free with a periodicity of 68 nm. Collagen type IV is
sphingoid bases derived from epidermal cerami- to be found in the basement membrane zone.
des and sebaceous triglyceride-derived fatty Type VII collagen is the main structural compo-
acids. nent of the anchoring fibrils and is primarily pro-
vided by keratinocytes.
Elastic fibers differ from collagen both struc-
1.4.5 Nails turally and chemically. They consist of two-
component aggregates: protein filaments and
NailsNails act to help grasp small objects and elastin, an amorphous material. Elastic fibers are
protect the fingertips against trauma and serve a fine in the papillary dermis, while the ones in the
sensory function. On average, fingernails expand reticular dermis are coarse.
by 0.1 mm/day, taking about 4–6 months to The dermis’ extracellular matrix consists of
remove a full nail plate. With toenails, the growth sulfated acid mucopolysaccharide, chondroitin
rate is much slower, with it taking 12–18 months sulfate and dermatan sulfate, acidic mucopoly-
to replace the big toenail [12]. saccharides, and electrolytes.
The types of keratin found in the nail are a
mixture of epidermal and hair types.
Nail cuticle is produced by proximal nailfold
keratinocytes, while matrix keratinocytes form Key Point
the nail layer. Collagen is the skin’s principal stress-
resistant substance. Elastic fibers do little
to resist deformation and skin tearing but
1.5 Dermis do play a role in maintaining elasticity.
formed. The dermal lymphatics and the nerves The impulses travel through the dorsal root gan-
are connected with the vascular plexus. glia to the central nervous system. Itch evoked by
histamine is transmitted by slow-conducting
unmyelinated C-polymodal neurons.
1.5.2 Muscles The autonomic nervous system’s postgangli-
onic adrenergic fibers regulate vasoconstriction,
Smooth muscle occurs in the skin as pilorum apocrine gland secretions, and contraction of hair
arrectores (hair erectors) and as the scrotum follicle arrector pili muscles. Cholinergic fibers
tunica dartos and in the areolas surrounding the mediate the secretion of eccrine glands.
nipples. The pilorum arrectores are attached to
the hair follicles below the sebaceous glands and
pull the hair follicle upward in contraction, pro- 1.5.4 Mast Cells
ducing gooseflesh (Fig. 1.1).
Specialized aggregates of smooth muscle cells Mast cells with type I or connective tissue mast
(glomus bodies) are found between arterioles and cells found in the dermis and play a major role in
venules and are especially prominent on the dig- normal immune response, as well as the suscepti-
its and lateral margins of the palms and soles. bility of the immediate form, contact allergy, and
Glomus bodies serve for blood shunting and tem- fibrosis. Measuring 7–11 μm in diameter, with
perature regulation. ample amphophilic cytoplasm and a thin, round
Striated voluntary muscle appears as the pla- central nucleus, normal mast cells in histological
tysma muscle in the skin of the neck and in the sections resemble fried eggs. Mast cells are dis-
face expression muscles. tinguished by containing up to 1000 granules in
diameter. One can see coarse particulate gran-
ules, crystalline granules, and scroll-containing
Pearls and Pitfalls granules. Their cell surface is occupied by numer-
The complex network of striated muscle, ous immunoglobulin E (IgE) glycoprotein recep-
fascia, and aponeurosis at the face and neck tor sites.
level is known as the superficial muscular
aponeurotic system (SMAS).
1.6 Subcutaneous Tissue
1.7 Functions of the Skin organs. The size, shape, and density of the hair
follicles vary among different sites of the body.
lá chắn cơ học The number of hair follicles remains unchanged
Skin plays a vital role in creating a mechanical
shield against the outside. The stratum corneum until middle life, but throughout life, there is a
chống mất nước changing balance between vellus and end hairs.
restricts skin water loss, while endogenous anti-
biotics, such as defensins and cathelicidins Hair may have significant social and psychologi-
derived from keratinocytes, provide an innate cal value, reflecting the notion that human skin
immune response against bacteria, viruses, and appearances and associated structures have a sig-
fungi [13]. The epidermis also includes a net- nificant impact on interpersonal relationships and
work of Langerhans cells, which serve as sentinel personal well-being.
cells whose primary function is to monitor the Related to the specific function of different
epidermal environment and initiate an immune body districts, the arrangement and size of elastic
response to microbial threats, although they may fibers in the dermis vary from very large fibers in
khả năng
also contribute to immune miễn dịchincủa
tolerance thedaskin. perianal skin to nearly no fibers in the scrotum.
In addition to these, an array of tissue-resident T There is also a marked difference in the supply of
cells, macrophages, and dendritic cells also con- cutaneous blood between areas of distensible
duct cutaneous immune surveillance in the der- skin such as the eyelid and more rigid areas such
mis, providing rapid and efficient immunological as fingertips.
backup to restore homeostasis if the epidermis is Subcutaneous fat plays a significant role in
đệm tổn thương, cách nhiệt, đệm calo
breached [14]. cushioning damage, supplying insulation and
Melanin, found mainly in basal keratinocytes, calorie buffer. Around 85% of the total fat of the
provides most of the protection from UV radia- body is found in subcutaneous tissue in non-
tion damage to the skin cell’s DNA. obese subjects. Fat also has an endocrine func-
điều hoà nhiệt độ tion and releases the hormone leptin, which acts
Thermoregulation is another essential feature
giãn mạch or vasoconstriction
of the skin. Vasodilatation co mạch of on the hypothalamus to regulate the metabolism
the deep or superficial plexuses of the blood ves- of hunger and energy.
sels helps to control heat loss. In all skin sites,
eccrine sweat glands are found to play a role in
Key Point
heat control through sweating. Apocrine sweat
Many cells in the dermis, subcutis, and hair
gland secretions contribute to body odor. Sebum,
follicles have stem cell properties and par-
which is secreted from sebaceous glands, pro-
ticipate in the wound healing process.
vides skin lubrication and waterproofing.
These cells have been called “precursors”
Nails protect the ends of the fingers and toes
and can differentiate between progeny of
and are essential for pinching objects.
the neural and mesodermal differentiation.
Skin also has a key function in the synthesis of
A subset of dermal and subcutaneous fibro-
different metabolic products, like vitamin D.
blasts can also have the potential for adipo-
Two primary forms of human skin exist: gla-
genic, osteogenic, chondrogenic, and
brous skin (unhairy skin) and hair-bearing skin.
neurogenic differentiation [15, 16].
On palms and soles, glabrous skin has a grooved
surface with alternating ridges and sulci giving
rise to dermatoglyphics (fingerprints). Glabrous
skin has a lightweight stratum corneum that can Take-Home Message
be up to 10 times thicker relative to other places • Skin is the most extensive organ of the
of the body . Glabrous skin also includes encap- body and consists of three layers: epi-
sulated sensory organs in the dermis and a lack of dermis, dermis, and subcutaneous fat.
hair follicles and sebaceous glands. Hair-bearing • Melanocytes are dendritic cells that dis-
skin, by contrast, has both hair follicles and seba- tribute packages of melanin pigment to
ceous glands but lacks encapsulated sensory
1 Anatomy and Physiology of the Skin 13
2.2 Types of Wound Healing wounds are left open to facilitate cleansing
các dạng làm lành vết thương and a correct response by the immune system.
Before analyzing the biological stages of wound After a few days, the edges of the wound,
healing, it is appropriate to clinically classify the which by now will be granulating, will be
different ways in which a wound can heal. brought together by a suture.
4. Healing in partial-thickness wounds:: it con-
1. Primary wound healing: this is the name of cerns wounds that do not affect the full-
the healing process of those wounds whose thickness skin, but only part of it, leaving a
clear and clean edges are brought together component of the dermis intact. In this case,
shortly after the traumatic event. It usually there will be a epithelialization starting from
involves sutured surgical or traumatic the cells of the underlying skin.
wounds.
2. Secondary wound healing: it represents the
type of healing that we find in all those cases 2.3 Phases of Wound Healing
in which a space remains between the two
skin flaps that will be filled only later by It is possible to distinguish four overlapping but
newly formed tissue. This is the case with different biological stages in wound healing:
most traumatic wounds and ulcers. hemostasis, inflammation, proliferation and
3. Tertiary intention healing or delayed wound remodeling (Table 2.1). Although a distinction
healing: in the case of particularly “dirty” and among these four independent phases can be eas-
contaminated wounds, e.g., following an ani- ily made for didactic purposes, in vivo the bound-
mal bite, it is not recommendable to opt for aries between the end of the previous phase and
the closure of the skin flaps by primary inten- the beginning of the next are not so defined
tion, as the infectious risk is too high. These (Fig. 2.1). 4 giai đoạn: cầm máu, viêm, tăng sinh, tái tạo
0 minutes
Hemostasis
24 - 48 hrs 3-7d
Inflammation
48 - 72 hrs 7 - 15 d
Proliferation
15 - 21 d 6 mo –1 yr
Remodeling
Granulation tissue begins to replace the provi- filaments they present (desmin, vimentin, actin)
sional matrix around the fourth day; it also acts as [4]. Their role is to produce the wound contrac-
a scaffold for keratinocyte migration. It is a tran- tion through specific cell–matrix interactions.
sitional replacement for normal dermis made up Remodeling of the extracellular matrix pro-
of a network of blood vessels, different cell types teins occurs by action of proteolytic enzymes
(fibroblasts, macrophages, endothelial cells), and produced by granulation tissue’s cells, metallo-
a net of random organized type III collagen fibers proteinases, and serine proteases.
[1]; during the remodeling phase, it will be Type III collagen is replaced by degradation
replaced by type I collagen fibers. by type I; there is a strong reduction in the
In this process, endothelial cells have the role number of cells and the disappearance of
of recreating blood vessels through angiogenesis. blood vessels. All this results in the formation
They are activated not only by local factors, such of the scar.
as tissues hypoxia and low pH values, but also by The resistance and the strength of the “new
all soluble mediators produced by macrophages tissue” gradually increase with time, from the
or fibroblasts, such as VEGF (vascular endothe- 20% of the strength of the skin not affected by the
lial growth factor), bFGF, and TGF-β. injury at 3 weeks to the 80% at almost one year.
To make reepithelization possible, basal cells This reflects the progressive reorganization of
(that are the only capable of proliferating) need to collagen fibers turnover and their cross-linking
lose desmosomes and hemidesmosomes, which process.
are connections between themselves and the Primary wound healing is characterized by a
basement membrane, respectively; this can hap- reduction of all the previously mentioned phases.
pen thanks to the release of growth factors such The stage of hemostasis is reduced; consequently,
as EGF (epidermal growth factor), KGF (kerati- the inflammatory one will also be reduced due to
nocyte growth factor), and TGF-α that dissolve a lesser stimulation and to a greater cleaning of
these bonds and let migration from the basal lay- the wound. All this will lead to a reduced stimula-
ers possible. tion of the proliferative phase based on a lower
need to lay new tissue to fill the gap. These are
the reasons why primary intention wounds usu-
2.3.4 Remodeling ally lead to the best cosmetic results. Also, as
wounds that heal by primary intention are often
After the wound gap has been filled in by the surgical wounds, the surgeon can decide the ori-
granulation tissue and keratinocytes have entation of the scar, and it is desirable to follow
migrated, the longest part of the human wound the lines of Langer to favor a correct orientation
healing starts: the remodeling phase. of the connective fibers.
It has been shown that it lasts 6–12 months
and can continue up to 2 years; it results in the
resolution of the initial inflammation process and Key Point
the restoration of the most similar possible aspect The four phases of wound healing are
of the wound tissue to the previous one; this clearly distinguishable from each other
aspect has very important clinical implications. only from a didactic point of view; in clini-
The goal of this phase is to produce the maxi- cal practice, the boundaries between the
mum tensile strength through extracellular matrix previous and the next are blurred. The
reorganization. Fibroblast of granulation tissue alteration of one or more of these four
change their phenotype and acquire typical char- phases leads to a derailment of the process,
acteristics of the smooth muscle cells, thus dif- with the production of pathological
ferentiating into myofibroblasts; they can have scarring.
different skeletal phenotypes, according to the
2 Wound Healing: Physiology and Pathology 19
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and wound healing. Nutr Clin Pract. 2010;25(1):61–8. https://www.woundsresearch.com/tsai
https://doi.org/10.1177/0884533609358997. 15. Carr RM, Oranu A, Khungar V. 乳鼠心肌提取 HHS
9. García C, Pino A, Jimenez N. In vitro characterization Public Access. Physiol Behav. 2016;176(1):139–48.
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Endoret—Gel as an autologous treatment for atrophic 16. Ault P, Plaza A, Paratz J. Scar massage for hyper-
scars. J Cosmetic Dermatol. 2020;19(7):1607–13. trophic burns scarring—a systematic review.
https://doi.org/10.1111/jocd.13212. Burns. 2018;44(1):24–38. https://doi.org/10.1016/j.
10. Berman B, Maderal A, Raphael B. Keloids and hyper- burns.2017.05.006.
trophic scars: pathophysiology, classification, and 17. Mokos ZB, Jović A, Grgurević L, et al. Current
treatment. Dermatol Surg. 2017;43:3–18. https://doi. therapeutic approach to hypertrophic scars. Front
org/10.1097/DSS.0000000000000819. Med. 2017;4:1–11. https://doi.org/10.3389/
11. Liechty KW, Adzick NS, Crombleholme fmed.2017.00083.
TM. Diminished interleukin 6 (IL-6) produc- 18. McGoldrick RB, Theodorakopoulou E, Azzopardi
tion during scarless human fetal wound repair. EA, Murison M. Lasers and ancillary treat-
Cytokine. 2000;6:671–6. https://doi.org/10.1006/ ments for scar management Part 2: Keloid, hyper-
cyto.1999.0598. trophic, pigmented and acne scars. Scars Burn
12. Van Den Broek LJ, Van Der Veer WM, De Jong Heal. 2017;3:205951311668980. https://doi.
EH, Gibbs S, Frank B. Suppressed inflammatory org/10.1177/2059513116689805.
gene expression during human hypertrophic scar 19. Issler-Fisher AC, Waibel JS, Donelan MB. Laser
compared to normotrophic scar formation. Exp modulation of hypertrophic scars: technique and prac-
Dermatol. 2015;24(8):623–9. https://doi.org/10.1111/ tice. Clin Plast Surg. 2017;44(4):757–66. https://doi.
exd.12739. org/10.1016/j.cps.2017.05.007.
13. Mustoe TA, Cooter RD, Gold MH, et al. International 20. Jaloux C, Bertrand B, Degardin N, Casanova D,
clinical recommendations on scar management. Plast Kerfant N, Philandrianos C. Keloid scars (part II):
Reconstr Surg. 2002;110(2):560–71. https://doi. treatment and prevention. Ann Chir Plast Esthet.
org/10.1097/00006534-200208000-00031. 2017;62(1):87–96. https://doi.org/10.1016/j.
14. Hsu KC, Luan CW, Tsai YW. Review of silicone gel anplas.2016.04.006.
sheeting and silicone gel for the prevention of hyper-
Complicated Wounds
3
Franco Bassetto, Carlotta Scarpa,
and Federico Facchin
Table 3.1 History and physical examination that influ- cutaneous oxygen pressure (tcPO2) measure-
ence healing ments, Doppler US, and biopsy for microbiology
Local Systemic and histopathology. X-rays allow bone evaluation
Age Malnutrition to recognize its involvement or the presence of
Infection Diabetes sharp edges.
Reduced blood flow Steroids
Nonetheless, pictures and documentation of
Reduced venous drainage Genetic causes
Neuropathy Alcohol abuse wound size, aspect, and infection should be part
Foreign body Smoking of patients’ charts.
Pressure Immunosuppression Additional imaging includes arteriography
Edema Connective tissue disorder and magnetic resonance.
Irradiation Chemotherapy
1. Arterial ulcers
A wound, acute or chronic, should be evalu- Arterial ulcers represent 5–10% of all
ated in order to define its specific etiopathogenic ulcers; they are caused by insufficient tissue
causes. History and physical examination perfusion and ischemia due to reduced arterial
(including ankle brachial index) allow the physi- flow. Other diseases such as diabetes or rheu-
cian to recognize local and systemic factors that matological diseases can overlap in the patho-
influence healing (Table 3.1) [3]. genesis of these ulcers. The clinical history is
characterized by rapid onset and evolution of
the ulcers, which can lead to the forefoot or
3.2 Ulcers leg loss, in the most severe cases of vascular
sự mất liên tục bề mặt occlusion.
3.2.1 Classification da có thể sâu dần, ảnh Arterial ulcers are usually located in lower
hưởng đến lớp dưới da limbs in the areas of bone prominence of the
Ulcers are characterized by a loss of continuity of foot, such as the peri-malleolar region. They
skin surface that can progressively deepen, affect- can affect fingertips or interphalangeal joints
ing subcutaneous tissues to involve muscles and such as the hand in patients suffering from
bone tissue. They usually affect lower limbs and rheumatoid arthritis and/or scleroderma. The
ụ ngồi, xương cùng lesions are well demarcated with the presence
areas of chronic pressure as sacrum and ischium.
Skin ulcers can be classified into different cat- of necrotic tissue, with pale perilesional areas,
egories depending on their etiopathogenesis: (1) easily subject to overinfection.
arterial ulcers, (2) venous ulcers, (3) lymphatic This injury can worsen, involving underly-
stasis ulcers, (4) ulcers or pressure lesions—oth- ing tissues such as tendons or bone (Fig. 3.1).
erwise known as bedsore ulcers, (5) ulcers of 2. Venous ulcers
neuropathic origin, (6) radiodermitic ulcers, (7) Venous ulcers are the most common type
drug extravasation ulcers, and (8) post-traumatic of ulcers, classically localized to the lower
ulcers. limbs triggered by minor traumas and wors-
ened due to insufficient return of retrograde
venous flow, related to an incompetence of the
3.2.2 Diagnosis venous valves or, more rarely, by a deficit in
the calf muscle pump.
History and physical examination are fundamen- The increase in venous pressure results in
tal to recognize the cause of the ulcer and to the deposition of pre-capillary fibrinogen with
define the principle of treatment. subsequent reduced oxygenation of tissues
Laboratory tests that allow recognizing factors and leukocyte entrapment. The greater ease of
impairing wound healing are CBC, albumin, pre- adherence of cells to the vessel walls with the
albumin, CRP, glucose level, and hemoglobin release of pro-inflammatory cytokines and
A1C. Additional diagnostic procedures are trans- chemotactic and free radicals finally brings to
3 Complicated Wounds 29
The process of soft tissue necrosis can involve Other complications include complications
the subcutaneous tissues until bone, resulting in “specific to the type of ulcers” such as ischemia
osteomyelitis. In addition, improper management in the affected area typical of the arterial vascular
of patients affected by diabetic foot can be asso- ulcer and which can also lead to the amputation
ciated with extensive progression to massive of the patient’s limb, or bone exposure resulting
necrosis of tissues, infections which in severe in osteomyelitis, especially for pressure ulcers.
cases can determine sepsis and patient death. In fact, the possibility that the natural contam-
Charcot foot is the emblematic aspect of dia- ination present at the bottom of an ulcer can turn
betic foot, which has become a bag of bones due into a real infectious episode is very high, espe-
to multiple stress fractures related to traumas thatcially in the patient suffering from comorbidities
the patient does not notice due to the absence of such as diabetes and obesity, and equally high is
algic sensation. the possible mortality associated with it, reaching
The diabetic foot can be classified into differ- peaks of 42% to 5 years in patients suffering from
ent stages of impairment depending on not only the diabetic foot.
the ulcer but also the infectious and/or ischemic Bacteria are quickly able to colonize the ulcer;
process, according to the Texas classification although most of them are commonly present on
(Table 3.4; Fig. 3.9). our skin and are part of the normal skin bacterial
BN bị gãy xương nhỏ/ trật khớp/ gãy
flora (see, for example, Staphylococcus epider-
xương nhưng do mất cảm giác nên ko
nhận biết + áp lực đè ép —> biến dạng
midis and/or Staphylococcus aureus), the absence
3.3.1 Diagnosis of an epidermal barrier facilitates their entry and
Thường kèm bệnh tk ngoại biên + mm ngoại vi allows the colonization of other bacterial species;
Diagnostic tools are similar to ones used in the presence of vascular insufficiency or comor-
chronic wounds. The neuropathic component of bidity such as diabetes and the presence of the
peripheral disease in diabetes requires a specific exuded can promote not only their multiplication
part of physical examination. but also and above all the establishment of the
so-called biofilm or a glycoproteic barrier pro-
duced by the bacteria themselves and that pre-
3.3.2 Possible Complications of vents the effectiveness of traditional treatments.
Complicated Wounds The persistence of the infectious state can, in
some cases, evolve into a much more fearsome
Of whatever origin they may be, patients affected framework and can lead to the death of the patient
by chronic ulcers can develop complications that if not recognized in a timely manner: necrotizing
do not allow or delay their healing with fasciitis.
chronicization. Initially characterized by the appearance of
Infection is definitely the most frequent and skin rash associated with edema and vesicles, this
common complication to all types of ulcers and infectious complication involves the fascial
diabetic foot and is also the most fearsome, being region and the underlying areas, which can result
the main cause of hospitalization. in a massive tissue necrosis.
3 Complicated Wounds 33
Fig. 3.12 Debridement, negative pressure therapy, and free flap coverage complicated diabetic foot
performing serial debridement, limiting or treat- lating growth factors such as VEGF or FGF
ing bacterial contaminations if necessary. In this (Fig. 3.13).
case, the skin graft or flap surgery should be post- In the case of local infection extending beyond
poned and performed to obtain a valid bottom of wounds as diffuse cellulitis or fasciitis, multidis-
the lesion (Fig. 3.12). ciplinary management should include urgent sur-
Alternatively, wound bed preparation tech- gical debridement with fasciotomy and
niques allow wound management to perform subsequent antibiotic therapy (Fig. 3.14).
definitive reconstruction or improving local The amputation of the affected area, espe-
wound treatment. (1) Hyperbaric oxygen therapy cially in cases of ischemia of the diabetic limb or
is very useful, especially in cases where there is foot, unfortunately still remains a possibility
an initial tissue suffering and/or an infectious (Fig. 3.15).
process. (2) Shock waves, vibrating acoustic
waves that stimulate the production of VEGF
with capillary formation, reduce the inflammatory 3.4 Osteomyelitis [15–22]
state by limiting the ability of leucocytes to
adhere to the vasal walls and stimulate fibroblasts Bone infection is one of the most severe compli-
to produce collagen. (3) Biofluorescence or the cations in wounds. Pathogens attach the bone in
administration of blue LED light is associated the sessile-based organization of biofilm due to
with or not with chromophore gel that is tasked spreads from soft tissues (i.e., contiguous spread),
with stimulating the proliferation of fibroblasts direct implantation of an infectious during sur-
and the consequent production of collagen, limit- gery, or penetrating trauma or hematogenous
ing bacterial charge by interacting with environ- seeding.
mental oxygen, modulating inflammation by Acute osteomyelitis occurs mainly in children
reducing TNF alpha and IL-6, and finally modu- and is of hematogenous origin. In adults, on the
3 Complicated Wounds 35
a b
Fig. 3.13 (a) pre-fluorescent light energy treatment; (b) after 2 weeks of fluorescent light energy treatment
Key Points
–– A wound is considered “chronic” after 6
to 8 weeks of impaired healing and heal-
ing failure despite interventions.
Fig. 3.16 Osteomyelitis in PET/CT
–– Classification of different ulcers is based
infection (Fig. 3.16). However, in chronic wounds on etiology; different severity scales are
with an exposed bone, they are not necessary and applicable for different wounds.
the main diagnostic aid is represented by tissue –– Single surgical debridement is not
biopsy for microbiologic and histologic enough for cure.
examination. –– Correct treatment is based on a multidis-
Multidisciplinary approaches, involving an ciplinary approach.
orthopedic surgeon, an infective disease consul- –– Prevention and early treatment are the
tant, a plastic surgeon, a microbiologist, are fun- most efficacious approach.
damental for the treatment and radicalization of
infective focus.
Osteomyelitis treatment is based on surgical Pearls and Pitfalls
debridement, systemic antibiotic therapy, and –– Many different etiologic factors are usu-
vascularized soft tissue coverage/repair ally associated and overlapped.
(Fig. 3.17). Surgical removal of necrotic and –– Single surgical debridement is not
demineralized bone should be aimed at obtaining enough for cure.
a vital and bleeding bone as confirmed by the –– Correct treatment is strongly dependent
paprika sign. The need for bone stabilization on specific and correct diagnosis.
should be evaluated preoperatively.
a b
Fig. 3.17 (a) Preoperative marking of SGAP flap in pressure ulcer; (b) postoperative at 1 month
3 Complicated Wounds 37
20. Perry CR, Pearson RL, Miller GA. Accuracy of cul- Infectious diseases society of america (IDSA) clini-
tures of material from swabbing of the superficial cal practice guidelines for the diagnosis and treatment
aspect of the wound and needle biopsy in the preop- of native vertebral osteomyelitis in adults. Clin Infect
erative assessment of osteomyelitis. J Bone Joint Surg Dis. 2015;61(6):e26–46.
Am. 1991;73(5):745–9. PMID: 2045400. 22. Miller W, Berg C, Wilson ML, Heard S, Knepper B,
21. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Young H. Risk factors for below-the-knee amputation
Widmer AF, Schmitt SK, Hendershot EF, Holtom in diabetic foot osteomyelitis after minor amputation.
PD, Huddleston PM 3rd, Petermann GW, Osmon J Am Podiatr Med Assoc. 2019;109(2):91–7. https://
DR. Infectious diseases society of america. 2015 doi.org/10.7547/16-143. PMID: 31135205.
Suture Techniques
4
Michele Maruccia, Rossella Elia,
and Paolo Claudio Marannino
• Biocompatible.
• Inert. Key Point
• Sterile. • The surgical hand and arm scrub proce-
• Ensuring maximum resistance in terms of dure must be performed in the scrub
wound support. suite before entry into the surgical suite/
• Guaranteeing minimum trauma to the tissues. operating room.
• Minimizing the inflammatory response of the • After scrubbing, you should hold up
body. your arms to allow water to drip off your
elbows.
• After scrubbing, dry with a sterile towel.
4.2 General Principles • Hold hands, forearms away from the
body and higher than elbows until put-
4.2.1 Handwashing and Patient ting on sterile gown and gloves.
Preparation
Hand hygiene forms the basis of antiseptic tech- Preoperative shaving must be done immedi-
niques aimed at reducing the incidence of noso- ately prior to the operation and with the least
comial and surgical site infections (SSIs). The amount of skin injury possible; it makes the sur-
contaminated hands of health workers are known gery, the suturing, and the dressing removal eas-
to result in nosocomial and surgical site infec- ier. Afterward, the skin at the incision site must
tions, which lead to severe morbidity and mortal- be prepared; the same antiseptic agents used for
ity, prolonged hospital stay, and increased hand scrubbing are available for preoperative
hospital costs. preparation of the skin. The iodophors, alcohol-
Therefore, the aim of surgical handwashing is containing products, and chlorhexidine gluco-
to clean up the colony-forming units (CFUs) of nate are the most commonly used agents.
bacteria, prevent their transfer, or reduce the Washing with antiseptics is begun at the exact
amount of permanent flora of the hands, which location where the incision will be made, mov-
would ultimately prevent surgical wound con- ing outward in a circular motion. A “no touch”
tamination from microorganisms found on the technique is used in which an area already
hands of the surgical team. washed is not returned to with the same sponge.
According to a recent review [1], there is no In septic, infected operations, it starts from the
firm evidence that one type of hand antisepsis is periphery toward the planned area of the opera-
better than another in reducing SSIs. tion. After the skin preparation, the disinfected
Chlorhexidine gluconate scrubs may reduce the operating area must be isolated from the non-
number of CFUs on hands compared with disinfected skin surfaces and body areas. The
povidone-iodine scrubs; however, the clinical rel- concept of local barrier protection has led to the
evance of this surrogate outcome is unclear. development of a vast array of different tech-
Alcohol rubs with additional antiseptic ingredi- niques with the goal of preventing microbial
ents may reduce CFUs compared with aqueous spread from the patient into the surgical field.
scrubs. With regard to the duration of hand anti- Ideal draping material should be impermeable to
sepsis, a 3-min initial scrub reduces CFUs on the fluid, resistant to mechanical damage, and should
hand compared with a 2-min scrub, but this is remain in place during manipulation. The initial
very low-quality evidence, and findings about a boundary should surround the planned incision
longer initial scrub and subsequent scrub dura- site. An additional superficial layer extends to
tions are not consistent. It is also unclear whether cover the body beyond the preparation site to
nail picks and brushes have a different impact on minimize the risk of contamination and allow
the number of CFUs remaining in the hand surgical personnel to maneuver while abiding by
(Videos 4.1 and 4.2). the aseptic technique.
4 Suture Techniques 41
index finger. During suturing, the forceps allow rings and body of the needle holder in the palm of
the surgeon to create counter traction and control their hand.
the position of the skin edge to facilitate passage
of the needle perpendicularly through the skin.
The forceps should also be used to grasp the Tips and Tricks
needle when repositioning it in the needle holder. When holding instruments
You should never touch the needle with your
fingers. • Use three-point control: have three
Scissors are sharp tools as well as scalpels; points of contact between hands, instru-
they differ in shape, length, strength, and angle. ment to increase precision.
They are formed by two articulated branches • Extend the index finger along the instru-
whose front part has the shape cutting edge and ment to provide extra control and
the back portion, the ring handle. Scissors are stability.
generally held with the thumb slightly in one ring • Place only fingertips through handle
and the ring finger in the other. The index finger loops: rotation comes from the wrist;
stabilizes the instrument by resting on the shaft. you can achieve greater control, and it is
The cut is generally performed with the scissors quicker to pick up, put down.
in the vertical position to ensure the total vision of
what is being sectioned, and never horizontally, of
the scissors because you cannot see the portion 4.2.3 Tissue Handling
underneath that is dissected. The tips of a scissor
must always face upward and never downward. The general principle of tissue handling is very
The four main functions of scissors are for cutting simple: be gentle at all times. This involves the
tissue, dissecting/undermining, suture removal, initial approach of injecting the skin and deeper
and bandage removal. The fine Metzenbaum scis- layers, marking the skin incision, draping the sur-
sors are commonly used for dissection purposes gical area, making the incision, and the careful
and may be used to cut lighter capsules and small use of retractors and other surgical instruments
fibrous tissue connections. The sturdier Mayo used during the procedure. Keeping the tissue
scissors are used to cut ligaments, larger fibrous layers moist during the procedure is very impor-
bands, and thick capsular tissues. Stitch or suture tant, and the use of frequent cool sterile flush and
scissors may be straight or curved but are usually suction is encouraged.
blunt to prevent damage to adjacent tissues during Lidocaine is the most frequently used infiltra-
the suture cutting process. tive local anesthetic. For diffuse infiltration, sev-
Needle holders, or needle drivers, come in a eral factors can reduce injection discomfort: slow
variety of styles and sizes. The selection of a nee- injection rate, use of small-bore needles (27-
dle holder from this wide choice of instruments gauge or higher), room-temperature injection
depends upon the nature of the procedure and the fluid, and injection with the use of small-volume
operator’s preference. They should be comfort- syringes. During infiltration, the surgeon must
able as well as functional. There are several tech- avoid intravascular injection. This complication
niques for holding the needle holder. The most can be minimized by frequent aspiration during
common method is to place the thumb and ring the introduction of the local anesthetic.
finger slightly into the instrument’s rings. This Whether the surgeon is completing a primary
allows them to pronate and supinate and to open wound closure or transferring a local flap, atten-
and close the jaws of the needle holder. Avoid tion should be directed toward the details of
inserting the fingers far into the rings of the wound approximation. Wound closure often
instrument since this will tie up the fingers and begins with the placement of subcutaneous
impede mobility. Some surgeons do not put their sutures. Proper eversion of the skin at the mar-
fingers into the rings at all and simply grasp the gin of the wound is required for accurate place-
4 Suture Techniques 43
ment of these sutures. Soft-tissue dissection is that run parallel to these lines naturally reapprox-
an essential component of wound closure. imate the skin edges. Lacerations that run at right
Proper technique includes a uniform undermin- angles to the tension lines tend to gape apart.
ing of the skin for primary wound closure. Figure 4.2 illustrates the typical orientation of
Dermal sutures provide most of the strength in Langer’s lines throughout the body.
wound closure, limiting scar stretching after
skin sutures are removed. Wound repair should
be performed with the least wound closure ten- 4.3 Closure Materials
sion necessary to approximate the wound mar-
gins (Video 4.3). 4.3.1 Sutures
Suture material
Absorbable Non-absorbable
Classification on the basis of the number of reaction, are less traumatic, may have less likeli-
threads: hood of infection, and provide a better cosmetic
result [2].
• Braided: they are sutures composed of several Classification on the basis of absorbability
thinly wound monofilaments around a central
core (GRAINED) or twisted around them- • Absorbable.
selves (PORTS). • Nonabsorbable.
• Monofilament: they are sutures made up of a
single monofilament that makes them com- Absorbable sutures lose their ability to give
pose the structure. over time mechanical wound support. As a result,
• Barbed: the presence of micro blades on the they are metabolized according to different
surface of the wire and the exclusive terminal mechanisms and “absorbed” by the body.
retention ring allows a suture to be carried out Nonabsorbable sutures maintain permanently or
without knots, ensuring a safe, effective and over a long period of time the ability to mechani-
fast closure. cally support the wound edges. They can undergo
a slow and gradual metabolization that, however,
Characteristically, multifilament suture mate- does not compromise their mechanical character-
rial (e.g., silk) tends to be easier to handle and tie, istics over time.
and knots in multifilament material are less likely The original absorbable suture materials were
to slip. On the other hand, monofilament materi- plain and chromic “catgut,” which actually con-
als (e.g., nylon or Prolene) are less traumatic sisted of processed collagen derived from the sub-
since they glide through tissues with less friction, mucosa of animal intestines. Plain gut is broken
and they may be associated with lower rates of down enzymatically after about 7 days. Chromic
infection. Since monofilament materials are more gut is collagen treated with chromium salts to
likely to slip, one generally ties knots with five or delay breakdown. Chromic gut typically loses its
six “throws” when using monofilament materials strength after 2–3 weeks and is completely
(in contrast to three throws with silk). Despite the digested after about 3 months. Now there are
greater number of knots required, monofilament many synthetic absorbable materials made from
materials such as nylon are generally preferred polymers (e.g., Vicryl and Monocryl). These
for skin closure because they stimulate less tissue materials are broken down nonenzymatically by
4 Suture Techniques 45
4.4.3 Vertical Mattress Suture passed deep to the opposite side of the wound,
where it exits the skin; the knot is then tied. A
A vertical mattress suture is a variation of a sim- half-buried horizontal suture exits with the same
ple interrupted suture. It consists of a simple principle explained above.
interrupted stitch placed wide and deep into the
wound edge and a second more superficial inter-
rupted stitch placed closer to the wound edge and 4.4.5 Intradermal Suture
in the opposite direction. This kind of suture
ensures good hemostasis (decreasing dead space) This technique involves a horizontally placed
and eversion of skin margins. It is useful for skin serpentine continuous suture within the dermal
closure of the scalp and articular surfaces layer (Fig. 4.7). Apposition of the skin is main-
(Fig. 4.6). The half-buried vertical mattress tained by longitudinal tension of the suture
suture is a modification of a vertical mattress along the incision. The ends are often taped to
suture: the needle penetrates the skin to the level prevent slippage. Because the suture never pen-
of the deep part of the dermis on one side of the etrates the epidermis, there are no external
wound, takes a bite in the deep part of the dermis suture marks.
on the opposite side without exiting the skin,
crosses back to the original side, and finally exits
the skin. Entry and exit points thus are kept on 4.4.6 Deep Closure
one side of the wound.
“Dead space,” which is an open cavity in the
internal recesses of the incision, can serve as a
4.4.4 Horizontal Mattress Suture reservoir for hematoma and microorganisms,
prevent accurate wound closure, and impair
A horizontal mattress suture is placed by entering wound healing. Properly placed deep sutures
the skin 5 mm to 1 cm from the wound edge. The should not only eliminate dead space in the
suture is passed deep in the dermis to the oppo- depths of the wound but also relieve tension from
site side of the suture line and exits the skin equi- the cutaneous suture line, thereby minimizing the
distant from the wound edge. The needle reenters postoperative widening of the wound [4].
the skin on the same side of the suture line 5 mm
to 1 cm lateral of the exit point. The stitch is
4.5 Postoperative Dressing Table 4.2 Skin suture size and removal time according
to different body areas
After completion of wound closure, a surgical Removal
dressing is usually applied. Most wounds should Body area Size time
be covered with an antibiotic ointment and a non- Face 5-0/6-0 6 days
adhesive dressing immediately after laceration Scalp 3-0 10–14 days
Chest/abdomen/ 2-0 to 4-0 10–14 days
repair. Limited evidence from one trial suggests
back
that antibiotic ointments such as topical bacitra- Limbs 3-0 10–14 days
cin zinc or combination ointments containing Hands 4-0 or 5-0 10–14 days
neomycin sulfate, bacitracin zinc, and polymyxin Nailbed 6-0 absorbable Absorbable
B sulfate significantly reduce the rates of wound suture
50 M. Maruccia et al.
phages from an M1 form to an inactive M2 form. necrosis). They protect from external agents but
These phenomena are at the basis of chronic do not alter the natural history of the disease.
inflammation, which can be seen in almost all When removed, they can damage granulation tis-
“difficult wounds” [1]. sue by adhering firmly to the wound as they are
Healing is more difficult to achieve when bac- dry dressings.
terial colonization involves four or more different
species, especially with anaerobic species. These
species are found in the deepest part of biofilm, 5.3 Hydrogel
where oxygen concentration is lower. The
bacterial species that most frequently colonize Hydrogel has a three-dimensional structure con-
this type of wound are S. aureus, Pseudomonas sisting of water-insoluble hydrophilic substances,
aeruginosa, Staphylococcus epidermidis, which therefore have the capacity to absorb it
Serratia marcescens, Streptococcus, and from the surrounding environment by eliminat-
Enterococcus spp. Combinations of the above- ing secretions. Advantages of this type of dress-
mentioned species coexist within the microenvi- ing are the high moisturizing effect that promotes
ronment and perform a synergistic action the autolytic cleansing of the necrotic tissue and
(exchange of genes involved in antibiotic resis- the faster passage of the cells from the edges
tance). Everything that has just been described toward the center of the wound. Being these
from a microbiological and molecular point of dressings also transparent, they allow doctors to
view must be taken into account in clinical prac- supervise the wound more often. The deteriora-
tice. Unfortunately, there is no gold standard tion of this “three-dimensional structure” is quite
diagnostic test to demonstrate the presence of slow, allowing the absorption of active substances
biofilm. The commonly used culture buffer is such as silver, which maintain their pharmaco-
exposed to several risks such as contamination logical properties longer. Silver has in fact an
and difficulty in collecting a suitable sample. The antibacterial effect. Indications for hydrogel
presence of bacterial biofilm is therefore thought application are surgical wounds, burns, radioder-
to be in all wounds that do not respond to stan- matitis, pressure ulcers, and all those wounds
dard treatments despite the patient’s general con- with minimal-to-moderate exudate.
dition. Plastic surgeons have the responsibility of
carrying out good surgical procedures, such as
wound cleansing and disinfection, without dam- 5.4 Hydrocolloids
aging the host tissues and eliminating bacterial and Hydrofibers
colonies efficiently. In such cases, dressings are
not only a physical barrier to external agents but Hydrocolloids and hydrofibers are made of a
also a means of hydrating and absorbing exu- variety of substances such as pectin and carboxy-
dates, conveying active ingredients and promot- methyl cellulose. These dressings gelify when in
ing the production of granulation tissue [2]. contact with the exudate absorbing it. Therefore,
they are ideal for the treatment of wounds with
moderate amounts of exudate. The same action
5.2 Standard Dressings mechanism is found in hydrofibers. These are
mainly made of cross-linked fibers of
Sterile gauze and bandages are used in clinical carboxymethyl-cellulose that are also used in the
practice because they are easy to handle and to case of loss of substances in deep wounds. They
find and affordable. They are useful in covering keep the microenvironment hydrated, becoming
surgical incisions and in dressing minor traumas a sort of gel. This is a fundamental condition for
(where there is no contamination or severe tissue tissue regeneration (Fig. 5.1).
5 Dressings and Dermal Substitutes 53
a b
Fig. 5.1 (a) Hydrocolloid dressing. (b) Sacral pressure Panel (NPUAP) guidelines recommend the usage of
ulcer. The European Pressure Ulcer Advisory Panel hydrocolloids for the management of pressure ulcers. (c)
(EPUAP) and The National Pressure Ulcer Advisory Hydrocolloid dressing application on the pressure ulcer
microenvironment well isolated. Clearly, these to fit different body sites (e.g., made in the shape
characteristics give these protections good auto- of a cast of the sacral area). During the initial
lytic properties and can be used for superficial stages (always bearing in mind the importance of
wounds during reepithelialization. taking action on the treatment of the patient with
pressure-relieving devices as well as frequent
mobilization), it is preferred to use films that reg-
Key Point
ulate gas exchange and have mild autolytic
Bacterial biofilm delays wound healing.
properties.
Surgical debridement removes necrotic tis-
Burns are another form of chronic injuries that
sue and, at the same time, eliminates bacte-
the plastic surgeon has to deal with on a daily
rial colonies. The dressing hydrates,
basis. These wounds are characterized by abun-
absorbs exudates, delivers active ingredi-
dant exudation and demarcation of necrotic tis-
ents, and promotes the formation of granu-
sue in the acute and subacute phase with extreme
lation tissue.
tendency to infection. Depending on the stages of
development of the burns, different dressings are
recommended: from very moist and occlusive
5.7 Advanced Dressings ones to hydrofiber with silver ions. Viscose-rayon
and Wound Types gauze soaked in petrolatum, which makes them
highly nonadherent, can help reduce pain during
Having listed and described the main dressings removal, especially in the case of extensive burns.
available on the market and used in clinical prac- Venous ulcers, on the other hand, are charac-
tice, it is fundamental to underline a very impor- terized by abundant necrotic tissue and moderate
tant issue: the choice of the correct dressing exudate on the wound surface, which promotes
according to the type of wound to be treated. bacterial infection and chronic inflammation.
Only the surgeon is capable of choosing the right Suitable for this type of lesion are alginates,
dressing. In doing that, he has first carried out hydrocolloids (also with a fat-colloid matrix that
both a good general objective examination (dia- blends with hydrocolloids) that can prevent bac-
betes mellitus, vasculopathy, obesity, smoking terial infection and promote wound healing, as
habit, autoimmune diseases) and a local one well as improving the venous stasis of the lower
(characteristics of the lesion, painfulness, evolu- limbs.
tion, etc.). Diabetic ulcers are characterized by a Lastly, radiodermatitis represents a particular
lack of oxygenation and regeneration in a chronic type of lesion, where a reduction of cell prolifera-
inflammatory phase. They can be therefore tion and collagen production can be seen. They
treated with foams enriched with silver ions, often have a de-epithelialized area, which does
hydrofibers, dressings enriched with hyaluronic not tend to heal. Film dressings are therefore rec-
acid, and nonadhesive dressings in order not to ommended. These lesions must be treated by
damage the soft layer of granulation tissue that is keeping them isolated from the external environ-
slowly growing. ment (pathogenic bacteria), removing the thin
Pressure ulcers are characterized by chronic layer of fibrin that covers them and protecting the
pressure alteration of the tissues at the level of regenerated fragile tissue.
bone protrusions. In these wounds, foams are Partial-thickness grafts taken with a derma-
indicated, in particular those made of silicon tome from different areas of the body raise the
multilayers. Polyurethane foams are recom- problem of dressings in donor areas. This area
mended thanks to their active substances, like causes discomfort to the patient like strong pain
silver, which have an antibacterial effect. Some for the first few days. Many researchers have
of these dressings have been developed espe- tried to identify a type of dressing that can be bet-
cially for this type of wound, as they are shaped ter used, although differing opinions remain. It
5 Dressings and Dermal Substitutes 55
Renoskin® (Perouse Plastie) has the same donor areas of partial-thickness skin graft. This
characteristics. can possibly lead to pain reduction.
Pelnac® (Gunze LTD) is an artificial dermal The third group consists of synthetic deriva-
matrix of porcine origin formed by a three- tives, which are not molecules found in nature
dimensional structure of atelocollagen covered and in human tissue. While this, on the one hand,
with a silicone film. It should be used with care in facilitates industrial production by eliminating
patients with allergic diathesis (asthma, urticaria, the purification and the elimination of antigenic
etc.), which has become very common in Europe molecules, on the other hand, it raises the oppo-
recently. It has shorter taking time compared to site problem. These molecules are recognized as
Integra, and during this phase, it almost seems to nonself in particular conditions, leading scien-
melt (be aware of differential diagnosis with tists to insert biomimetic protein molecules to
infection). “deceive” the cells of the immune system and
Hyalomatrix® PA (Fidia Advanced prevent a “foreign body” type reaction. Therefore,
Biopolymers S.R.L.) is a matrix of avian origin, it is useful to stress that the action of the dermal
consisting of an active layer and a semipermeable substitute is similar to a scale that sees on one
silicone film. The first layer is made up of an plate the ability of the host cells to degrade the
esterified derivative of hyaluronic acid, which matrix and on the other the capacity of the host
promotes dermal regeneration, while the silicone cells to integrate within the matrix itself. If the
foil controls fluid loss. It is recommended as a balance is not perfect, there will be either reab-
temporary dressing, therefore used in skin losses sorption of the matrix without colonization by
involving a large percentage of body surface area. the host tissues or a foreign body reaction with
Apligraf® (Organogenesis, Inc.) is the only scar tissue formation [9].
biological dermal substitute made from neonatal The main synthetic substitutes currently used
fibroblast cultures embedded in a type I bovine in clinical practice are listed below.
collagen matrix. It is suitable for all the condi- Dermagraft® (Advanced Biohealing) is com-
tions listed above including second-degree burn posed of polygalactin and human fibroblasts;
and higher. Dermagen® (Genevrier) is composed of glycos-
Oasis® Wound Matrix—Oasis® Burn Matrix aminoglycans, collagen, and chitin; Biobrane®
(Healthpoint) is an acellular biological matrix (Smith & Nephew) consists of a silicone film
composed of collagen and submucosa obtained and a nylon that traps the clots and makes the
from the small intestine of pigs. It is not recom- substitute adhere to the wound until reepitheli-
mended in third-degree burns. alization; and Suprathel® (PolyMedics
Veloderm® (BTC SRL) is the only dermal sub- Innovations GmgH (PMI) consists of a resorb-
stitute of vegetable origin consisting of a particu- able membrane of d,l-polylactide. The indica-
lar microcrystalline cellulose with low tions, with small variations between one
polymerization and a high level of crystallinity. It substitute and another, remain the same: trau-
has been proven that it is extremely useful as a matic wounds after stabilization and good surgi-
temporary dressing in wounds and burns (up to cal debridement, first- and second-degree burns,
the second degree deep) because it helps contain and, for some, third-degree burns, chronic ulcers
massive fluid loss and allows you to overcome after accurate surgical debridement (Figs. 5.2
acute phases. It can be used as a dressing on and 5.3).
58 G. Delia et al.
a b
c d
e f
Fig. 5.2 (a) Left laterocervical sarcoma. (b) Tumor exci- tute application and removal of the silicone lamina. (e)
sion with laterocervical lymphadenectomy. (c) Application Partial-thickness skin graft application. (f) 1-month post-
of dermal substitute. (d) Three weeks after dermal substi- operative follow-up
5 Dressings and Dermal Substitutes 59
a b
c d
Fig. 5.3 (a) Trauma of the posterior surface of the left leg application with silicone layer. (d) Partial-thickness skin
with skin degloving. (b) Debridement and dermal substi- graft application. (e) 1-month postoperative follow-up
tute application. (c) Three weeks after dermal substitute
60 G. Delia et al.
nourished by O2 and metabolites within the host based on a crossover wild-type/green fluorescent
fluid from the wound bed [3, 4]. This phase, which protein (WT/GFP) skin transplantation model,
is called “imbibition,” may vary in duration, was designed in order to clarify the unanswered
depending mainly on the characteristics of the questions about graft revascularization and to
recipient site (vascularity of wound bed), and lasts establish the origin of the skin graft vasculature
up to several days. This mechanism is commonly [24]. The data indicated a replacement rate of
believed to be responsible for graft survival in this graft native vascular network close to 100% at
ischemic period, which lasts from graft harvesting the periphery of the graft vs. 50–60% at the cen-
to the revascularization phase, and is characterized ter of the graft, suggesting heterogeneous mecha-
by anaerobic metabolism [5–7]. The term “serum nisms involved in graft revascularization and a
imbibition”, introduced by Converse in 1969, centripetal vascular replacement pattern.
refers to the changes in graft weight, as it grows to
up to 40% of the initial weight within the first 24 h
and decreases until it reaches a final weight gain of 6.3.3 Phase 3: Maturation
5% 1 week after grafting [8].
Along with other authors, Converse rejected Skin grafts may take up to 1 year to be fully inte-
the theory that plasma circulation gives meta- grated, being this process variable in duration
bolic supply to the graft, being the serum only a according to underlying clinical conditions and
moisturizing element for the graft [9, 10]. “Serum to the etiology of the defect that led to graft
imbibition” would allow the graft vessels to reconstruction. During the first 4 days after graft-
remain patent and the creation of a connection ing, the epidermis of a skin graft doubles in thick-
between graft and recipient sites through serum ness due to the nuclear and cytoplasmic swelling
fibrinogen bridges. of epidermal cells, cellular migration to the sur-
face of the graft, and an increased cellular turn-
over, which lasts until 4 weeks after grafting [25,
26]. The cross-linking process between collagen
6.3.2 Phase 2: Revascularization
fibers in the wound interface allows the extracel-
lular matrix to develop resistance to mechanical
Different studies have demonstrated that, after
insults. Within 5 months after skin grafting, in a
48–72 h, there is a growth of 10–11 μm diameter
full-thickness skin graft, 85% of native skin col-
vessels in the fibrine interface between graft and
lagen is replaced, but the percentage decreases to
recipient site [11]. Different theories have been
50% in split-thickness skin grafts [27, 28].
proposed to explain graft revascularization,
Nonnative skin graft fibroblasts convert into
including anastomoses (inosculation) between
myofibroblasts developing alpha-smooth-muscle
wound bed capillaries and graft native vessels,
actin (alpha-SMA) fibers, which exert contractile
and angiogenesis (or neovascularization) from
forces on the extracellular matrix determining
the recipient site to the graft, with new vessels
wound contraction. Scars from skin grafts con-
replacing graft native vessels [12–17]. The best
tinue to modify for several years, and scar man-
evidence nowadays supports the theory of endo-
agement may be required, especially in burn
thelial cell proliferation from the recipient site to
victims or children.
the graft tissue, using the preexistent vascular
network of the graft itself, while in the graft, the
endothelial cells gradually degenerate [14, 15, Key Point
18–20]. An in vivo model, developed by The physiologic process of graft take can
Lindenblatt in 2010, supports this theory, sug- be divided into three phases: imbibition,
gesting the role of angiogenesis as a primary fac- responsible for initial graft survival; revas-
tor in graft revascularization through the fibrine cularization, which brings new blood sup-
interface between the skin graft and the wound ply to the graft; and maturation, which
bed, leading to reperfusion of graft native circula- determines complete tissue integration.
tion [21–23]. A study by Calcagni et al. in 2011, SInh lí của mảnh ghép chia làm 3 pha:
hấp thụ, tái tạo mạch máu, trưởng thành
64 E. Cigna et al.
Table 6.1 Advantages, disadvantages, and possible indications of full-thickness skin grafts and thin and thick STSGs
(split-thickness skin grafts)
chỉ định
Advantages Disadvantages Indications
FTSG – Optimal skin quality and esthetic – Low availability – Facial defects
outcome tối ưu thẩm mỹ – Lower rate of graft take – Joint surfaces
– No secondary contraction
Thin – Optimal graft take – Great amount of secondary – Burn wounds
STSG – Faster donor site reepithelization contraction – Chronic and acute wounds with
– Possibility of meshing – Poor esthetic outcome an adequate wound bed
– Possibility of reharvesting – High risk of hyper- or
hypo-pigmentation
Thick – Good graft take – Secondary contraction
STSG – Slower donor site reepithelization – Poor esthetic outcome
– Possibility of meshing –Risk of hyper- or
– Possibility of reharvesting hypo-pigmentation
– Greater structural stability
(compared to thin STSG)
Key Point
Coleman’s lipostructure technique.
This widely used technique for lipo-
structure consists of gentle harvesting of
the fat, centrifugation up to 3000 rpm to
remove nonviable components, and injec-
tion of the fat in small aliquots. This
ensures maximizing the contact surface
area of the fatty parcel, hence reducing the
quote of adipose tissue necrosis [38].
Table 6.3 Common characteristics of cancellous and intrinsically characterizes cartilaginous tissues.
cortical bone grafts Commonly used donor sites include auricular,
Cancellous Cortical bone nasal, and rib cartilages. Auricular cartilage is
Characteristic bone grafts grafts the most versatile graft because of its adaptabil-
Immediate strength Low High
ity to be contoured into different shapes.
and support
Osteogenic High Low Moreover, it can be harvested under local anes-
properties thesia using retro auricular incisions, with low
Incorporation 2 weeks 1–2 months morbidity of the donor site. Auricular cartilage
Maximum length 6 cm 12 cm grafts are often used for ear, nasal, tarsal, and
nipple reconstruction (Fig. 6.9). Nasal cartilage
grafts can be obtained from the septum, and
they can be harvested simply as cartilage or as
composite chondromucosal grafts for eyelid
reconstruction. Rib cartilage is the best option
when a large amount of cartilage is needed. For
this reason, the costal cartilage graft is often
used as a cartilage framework for total ear
reconstruction and for the reconstruction of the
nose and the nipple, in septorhinoplasties, and
in tracheal reconstruction [41].
Fig. 6.8 Cadaveric bank femoris prepared for allogenic 6.9 Vascular Graft
bone grafting in skeletal limb reconstruction
Vascular grafts may be utilized isotopically or,
indicated in some cases (Fig. 6.8). Methods for less commonly, heterotopically for conjunctival
bone preservation and sterilization have improved reconstruction.
during the last decades and allow to obtain acel- They are particularly useful for microsurgical
lular scaffolds that are mainly repopulated by anastomoses when a deficit of vessel length, size
ingrowth of recipient mesenchymal cells. mismatch, and tension over the pedicle are
Disadvantages of this technique are the antige- encountered during surgery (Fig. 6.10). There
nicity of the graft and the lack of osteogenic seems to be an association between interposition
properties in the prepared allografts. The com- vein grafting and free-flap complications, but
bined approach consisting of allogenic bone results are still controversial [42, 43]. Commonly
grafts and autogenous vascularized/nonvascular- used vein grafts are the great or the lesser saphe-
ized bone grafts can overcome most of the limita- nous vein, the cephalic vein, the volar forearm
tions with good and promising results [40]. vein, and the dorsal foot vein.
Arterial grafts present fewer disadvantages
when used for the reconstruction of vascular defi-
6.8 Cartilage Graft cits, mostly due to their structural characteristics.
Common donor sites are the subscapular artery
Cartilage grafts are widely utilized isotopically and its ramifications, the anterior and posterior
in ear and nose reconstruction and heterotopi- interosseous arteries, the radial or ulnar arteries,
cally for tarsal eyelid reconstruction. Graft the deep or superficial inferior epigastric arteries,
intake is not predictable, as grafted tissue may the dorsalis pedis artery, and the descending
exhibit various amounts of resorption, and it is branch of the lateral circumflex femoral artery
exposed to infection due to the avascularity that (LCFA).
6 Grafts in Plastic Surgery 71
Fig. 6.9 Inset of a cartilage graft for reconstruction of the Fig. 6.11 Sural nerve graft harvested from the right leg.
inferior eyelid tarsum. The cartilage is harvested from the Four small incisions are used for dissecting the length of
concha of the homolateral ear and sutured to the residual the nerve needed. Long nerve grafts can be harvested from
tarsum. A Mustardè flap is then prepared for the recon- this anatomical area
struction of the skin defect
cells included in the graft and in the distal end of
the injured nerve degenerate. The nerve graft,
mostly composed of glial supportive cells, guides
axon regeneration toward the distal end. The
sural nerve is the most commonly used graft as it
can reconstruct long nervous defects and because
its harvest causes low sensitive donor site mor-
bidity (Fig. 6.11). Other nerves, such as the
branch from the obturator nerve to the gracilis
and the distal anterior interosseous nerve, are less
commonly used. When possible, donor nerves
close to the defect should be evaluated for func-
tional transfer if the resulting benefit is greater
Fig. 6.10 Saphenous vein graft for the reconstruction of than the functional loss of the donor site.
a vascular defect in a microsurgical case. The vein may be Biological and synthetic conduits have been used
used for the reconstruction of both arterial and venous for addressing peripheral nerve gaps due to their
defects
ability to induce nerve growth. Biological con-
duits commonly include bone, artery, and vein
with or without muscle graft filling. Biodegradable
6.10 Nerve Graft synthetic conduits include polyglycolic acid
polymers [45]. Acellular human processed nerve
When reconstructing nerve defects, nerves can be allografts (ANAs) may be used for nerve recon-
transferred as a simple graft or together with a struction. They are composed of epineurium, fas-
vascular pedicle, as a vascularized nerve graft. It cicles, endoneural tubes, and laminin. With these
is recommended to use a free vascularized nerve characteristics, ANAs act as 3D scaffolds that are
graft when the gap distance between proximal repopulated by recipient cells similarly to autolo-
and distal ends is greater than 6 cm. For gaps gous grafts. Nevertheless, autografts have been
smaller than 6 cm, it has been demonstrated that demonstrated superior to ANAs and conduits,
conventional grafts are equivalent to free vascu- and the latter resulted inferior to ANAs [46].
larized grafts in terms of functional recovery Transplanting Schwann cells into ANAs in vitro
[44]. When a nerve graft is used, all neuronal has proved to improve functional regeneration,
72 E. Cigna et al.
reaching results of functionality similar to the use cellular products, and growth factor products.
of autografts [47]. Acellular products, such as collagen and decel-
lularized matrices or fibrin, are constructed using
a combination of synthetic and natural materials
6.11 Fascial and Tendon Graft without cells. These products promote wound
healing by improving the wound microenviron-
The use of fascial grafts is related to their ability ment, which facilitates endogenous tissue heal-
to reinforce, sustain, or substitute damaged struc- ing, and providing temporary wound coverage.
tures. For their structural characteristics, fascial Cellular products are commonly composed of
grafts are commonly used to achieve symmetry cultured keratinocytes with synthetic scaffolds.
in static procedures in facial paralysis surgery, Some products are composed of a combination of
alone or as an adjunct to dynamic procedures. fibroblasts, keratinocytes, and scaffolds. Recently
With these indications, they can be anchored to keratinocytes, fibroblasts, and melanocytes were
the labial commissure to open the oral orifice or utilized to recreate the structure of the physiolog-
to the tarsum for closing the eyelid rim. Moreover, ical skin [48]. Similarly, with the aid of cell cul-
they can be used for the correction of palpebral tures, it has been possible to recreate a layered
ptosis by suspending the upper ptotic eyelid to mucosa that has been clinically utilized for treat-
the frontalis muscle. The preferred donor site for ing vaginal deficits such as those of Mayer–
harvesting fascial grafts is the tensor fascia latae Rokitansky syndrome or gender reassignment
or the deep temporal fascia. For this purpose, a surgery. Growth factor products, such as platelet-
surgical instrument called “fasciotome” has been derived factors, which are the most studied at the
developed to minimize the donor site morbidity moment, are soluble factors that promote healing
derived from an open approach, which usually by stimulating the regeneration of resident cells.
comprehends a wide incision and exposure of tis- Although all of these devices hold promise, none
sues, allowing graft harvest through two small has been able to mimic the healing capacity of
skin incisions. Tendons may be used for the same native skin.
indications of fascial grafts. Palmaris longus, Autologous fat grafting allows isolation of
plantaris, or extensor digitorum longus tendons large amounts of fat-derived stem cells. Plastic
are commonly used for grafting because of their surgeons have investigated cells harvested in
low donor site morbidity. lipoaspirates as cell sources for bioengineered
tissues. Adipocytes are harvested from the
lipoaspirate and expanded on three-dimensional
6.12 Tissue Engineering scaffolds with the aim of recreating volumetric
material to address deep defects. Studies exam-
Regenerative surgery is considered an interdisci- ined the expansion of the fat-derived stem cells
plinary setting of research, and its clinical appli- ex vivo with their reimplantation and demon-
cation is aimed at repairing, substituting, or strated improved volume retention than tradi-
regenerating cells, organs, and tissues in order to tional aspirates. Nevertheless, tissue-engineered
restore altered structures or functions. Tissue fat is still experimental.
engineering consists of the creation “ex vivo” of With regard to bone grafting, most of the stud-
biological substitutes, overcoming most of the ied devices use synthetic polymer and processed
limitations of natural and synthetic biomaterials. biologic materials to provide acellular osteocon-
Numerous attempts in recreating human tissues ductive scaffolds with and without osteoinduc-
have been made over the years; only a few are tive ligands. A human decellularized bone
briefly summarized in this section. allograft with bone morphogenetic protein 2 has
Commercial products currently available for been developed to promote osteoinduction and
the treatment of skin and mucosal defects are osteoconduction. New studies are evaluating the
divided into three categories: acellular products, feasibility of ex vivo constructs with endothelial
6 Grafts in Plastic Surgery 73
24. Calcagni M, Althaus MK, Knapik AD, et al. In vivo combined with allogenic bone graft. Cytotherapy.
visualization of the origination of skin graft vascula- 2013;15:571–7.
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Res. 2011;82(3):237–45. chondrium. In: McCarthy JC, editor. Plastic Surgery.
25. Medawar PB. The behaviour and fate of skin auto- Philadelphia: WB Saunders; 1990. p. 559–82.
grafts and skin homografts in rabbits: a report to the 42. Khouri RK, Cooley BC, Kunselman AR, et al. A pro-
War Wounds Committee of the Medical Research spective study of microvascular free–flap surgery and
Council. J Anat. 1944;78(Pt 5):176–99. outcome. Plast Reconstr Surg. 1998;102:711–21.
26. Medawar PB. A second study of the behaviour and 43. Germann G, Steinau HU. The clinical reliability of
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Wounds Committee of the Medical Research Council. 1996;12:11–7.
J Anat. 1945;79(Pt 4):157–76. 44. Doi K, Tamaru K, Sakai K, et al. A comparison of vas-
27. Rudolph R, Klein L. Isotopic measurement of col- cularized and conventional sural nerve grafts. J Hand
lagen turnover in skin grafts. Surg Forum. 1971;22: Surg Am. 1992;17:670–6.
489–91. 45. Meek MF, Coert JH. Clinical use of nerve conduits
28. Ohuchi K, Tsurufuji S. Degradation and turnover in peripheralnerve repair; review of the literature. J
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34. Avram MR, Finney R, Rogers N. Hair Transplantation human induced pluripotent stem cells into endothe-
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Further Reading
40. Fernandez-Bances I, Perez-Basterrechea M, Perez-
Lopez S, et al. Repair of long-bone pseudoarthrosis Peter C. Neligan. Plastic surgery. fourth edition. Elsevier.
with autologous bone marrow mononuclear cells Volume 1: Principles. Chap. 15, pp. 214–29.
History of Reconstructive
Microsurgery: From Myth
7
to Reality
Isao Koshima
I. Koshima (*)
Plastic Surgery & International Center for
Lymphedema (ICL), Hiroshima University Hospital,
Hiroshima City, Japan
In Japan, vascular anastomosis began in the teacher, Director Seiichi Omori. In 1993, Ueba of
1960s using a microscope made in Japan. In Kyoto University Orthopedic Surgery also suc-
1965, Tamai of the Nara Medical University ceeded in the world’s first free vascularized fibula
Orthopedic Surgery succeeded in completely cut- transfer. At that time, it was very difficult for
ting and re-planting the thumb for the first time in Japanese people to submit a treatise in English.
the world [1]. Behind this feat was the presence In the early 1968, Tamai reported the effec-
of the world’s latest anastomotic needles and sur- tiveness of vascularized muscle transfer in dogs.
gical microscopes. His teacher, Professor Onchi, In 1976, Ikuta of Hiroshima University reported
visited Jacobson at the University of Vermont for the first time in the world a dynamic recon-
shortly before, and a finger artery anastomosis struction technique in which the muscles of the
was performed using the latest Ethicon micro- forearm of a boy with Volkmann contracture
anastomosis needle that had been brought back to were reconstructed by a pectoralis major muscle
Nara Medical University. Onchi’s passion was transplant with a neurovascular pedicle. The
hot, and he bought the latest expensive Zeiss transplanted pectoralis major muscle began to
microscope at Nara Medical University ahead of move with the forearm, the fingers began to
other universities and was preparing for the move, and the function of the hand was restored.
world’s first feat. Due to the achievements of Behind Ikuta’s feat was the enthusiastic support
Onchi and Tamai, many young followers in Japan of his teacher, Professor Kenya Tsuge. At the
appeared, and from around this time, the founda- same time, Kubo of Hiroshima University
tion for Japan to lead the reconstruction tech- Orthopedic Surgery reported in his experiment
nique using microsurgery was laid. Also, from that muscles normally recovered with an electron
that time on, the competition began to occur in microscopic approach. In the same year (1976),
the field of plastic surgery as to who would be the Harii succeeded in voluntarily reconstructing
first in the world to perform flap transfer and free established facial palsy by transplanting gracilis
flap using microsurgery. Finally, in 1973, Daniel muscle with a neurovascular pattern from the
and Taylor reported the world’s first successful thigh for old facial nerve paralysis. In this way,
case of transplanting a free groin flap for a skin microsurgery pioneers Tamai, Harii, Ikuta, and
soft-tissue defect in the ankle joint and perform- Ueba played an active role at the forefront of the
ing vascular anastomosis [2]. world in the early 1970s, and as a result, became
Daniel was sent from McGill University in the foundation of Japan’s development ahead of
Canada to train under O’Brien in Melbourne, the world for 30 years to this day.
Australia, which was at the forefront of microsur-
gery. Although he was still in his twenties, the
surgery seemed to be so good that he could per- 7.3 I ntroducing Perforator Flap
form vascular anastomosis after a short training. and Fighting Against
Traditional Microsurgery by
the Authority
7.2 istory on Free Flap
H
Transfers in Japan In 1984, Song in China reported anterolateral
thigh flap (ALT flap) and anteromedial thigh flap
In Japan, in 1971, Harii of Tokyo Police Hospital (AMT flap) [3]. The flap as large as 30 cm in
succeeded in the world’s first supercharged chest length can be supplied by only one perforator
wall flap in the field of plastic surgery, and in with less than 1 mm in diameter. That being the
1972, free superficial temporal artery flap and feature, they reported it as a septocutaneous per-
skull for bald hair due to burn scars. Successful forator flap. While as a nutrient vessel, it sur-
free omentum transfer for exposed deep burn passed the common sense in its thinness.
ulcers was also achieved. Behind the feat of In 1986, Koshima applied island ALT flap to
Harii, there was a great deal of support from his the reconstruction of genital defect, followed by
80 I. Koshima
Lin in 1988. In 1989, Koshima reconstructed Moreover, from the middle of 1990, the DIEP
wide loss of lower jaw with combined vascular- flap had become the first choice for and was
ized iliac bone flap and ALT flap. Based on such widely applied in minimally invasive breast
clinical cases, the anatomy of its nourishing blood reconstruction in Europe and the United States,
vessels was reported by Xu [4] and Koshima [5] replacing the traditional rectus abdominis muscu-
in the late 1980s. In 1989, a deep inferior epigas- locutaneous flap. In 1997, the workshop on per-
tric perforator flap (DIEP flap) was reported by forator flap was started in Europe; later on, the
Koshima [6] (Fig. 7.1a, b). And accordingly, the thoracodorsal artery perforator flap (TAP flap)
basic concept of the perforator flap was set up. was presented by Angrigiani in Argentina in 1996
In 1993, a series of head and neck reconstruc- [8]. Together with TAP flap pedicled with inter-
tions with ALT flap was reported by Koshima [7] muscular capillary [9, 10], ALT flap, and DIEP
(Fig. 7.2a, b). Afterward, Kimura and Kimata flap, the three flaps are started to be shown on live
established its validity by applying ALT flap to surgery of the international perforator training
head and neck reconstruction. session. Until now, more than 5000 learners have
From 2000, head and neck reconstruction with learned the elevation of such flaps, which are
such ALT flap became popular in the world then being applied worldwide.
(Figs. 7.3 and 7.4). Until now, according to Wei TAP flap was initially reported in 1995 by
in Taiwan and Yu in Anderson Cancer Center, Angrigiani in Argentina as a new flap pedicled by a
ALT has been the primary choice in head and thick thoracodorsal artery perforator to replace the
neck reconstruction. latissimus dorsi musle flap [8]. In my opinion, per-
a b
Fig. 7.1 (a and b) The world’s first case of a free DIEP flap (surgery on 1987.12.25., Koshima I, et al. J Reconstr
Microsurg, 7: 313–316.1991)
7 History of Reconstructive Microsurgery: From Myth to Reality 81
a b
Fig. 7.2 (a and b) The world’s first case of head and neck on 1985.9.27. Koshima et al., Jap J of Plast Reconstr Surg.
reconstruction using ALT flap.. After this, head and neck 6: 260–267, 1986)
reconstruction with the ALT flap was established (surgery
forator as thick as 0.8 mm in diameter is usually Belgium played a central role in the first interna-
absent. Thus, currently, it is not popularly applied. tional perforator flap in June 1997 with the inten-
However, according to my experience, the thin cap- tion of having young reconstructive surgeons
illary perforator (diverged from descending lateral around the world master of the perforator flap
branch of a thoracodorsal artery) can support the big procedure. A flap training course was launched
flap [9, 10]. To elevate the flap in 30 min for applica- (Figs. 7.5 and 7.6). In this workshop, we actually
tion, a new capillary perforator flap is believed to be exhibited live surgery and had them experience
the most popular free flap in clinical use. the raising of a skin flap using a fresh cadaver.
Since around 1987, the idea of a perforator Many young reconstructive surgeons learned the
flap is that a huge flap can live only with a perfo- perforator flap in a short period of time during
rator flap of about 0.5 mm without inserting mus- this course. The response was great, and then the
cle or fascia with a conventional myocutaneous perforator flap spread mainly in Europe. In the
flap or fascia flap. The DIEP flap [6] was devised workshop, live surgery such as ALT flap and pos-
from this concept, and minimally invasive flap terior tibial perforator propeller flap (Koshima),
transfer that does not include muscle and fascia DIEP flap ((Allen), GAP flap (Blondeel), and
as much as possible begins. Initially, various per- lymph venous anastomosis (Koshima) was dem-
forator flaps were not easily understood not only onstrated for the first time in Europe. This will be
in Japan but also overseas, and they overturned the 25th time until 2019, and the number of par-
the conventional surgical techniques, so there ticipants is 200 to 600 each time, and more than
were many criticisms from authorities in each 5000 audiences have been attended so far.
area, especially in Japan. Koshima of Japan, Unfortunately, in Japan, there is always strong
Allen of the United States, and Blondeel of resistance from authoritative doctors and aca-
82 I. Koshima
$7
A
$/
37
B )
A /&
I
$7
7'
&
F '3
/'
Melbourne in 1976 [12]. He performed a vascu- sciatic nerve of rats by Koshima et al. [13–15],
larized nerve transfer of the radial nerve with the vascularized nerve transfer was performed to a
radial arteries and veins as the vascular pedicle to transplant bed surrounded by scars, compared
the defect of the median nerve. After that, with the conventional method. In the experimen-
although vascularized nerve transfer has theoreti- tal model, early regeneration of axons and high
cal advantages over conventional nerve graft, density of large-diameter sciatic nerves have
there is no suitable transplanted nerve for vascu- been demonstrated, and the e xcellence of vascu-
larized nerve transfer, and there are technical dif- larized nerve transfer has been recognized. In
ficulties over conventional methods. It did not addition, Rose performed vascularized nerve
reach the general public because no clear clinical transfer of the deep peroneal nerve in cases of
comparison was made. According to an experi- finger nerve injury and gained excellent sensory
mental study of vascularized nerve transfer of the recovery, and regained interest in vascularized
84 I. Koshima
Fig. 7.6 Faculty members of the first International (Belgium), and others participated. Live surgeries (DIEP
Course on Perforator Flap. Koshima (Japan), Allen flap, ALT flap, GAP flap) were demonstrated (June 1997,
(United States), Blondeel (Belgium), Show (UCLA), University of Belgium-Ghent)
Webster (Scotland), Monstrey (Belgium), Konraad
nerve transfer [16]. When transplanting a thin arteries and veins is clinically restricted, the
nerve to the main nerve of the upper limb, it is arterial nerve feeds the graft by arterial blood
necessary to fold it into multiple pieces and trans- circulation using the nerve graft having only the
plant it as a cable graft. The clinical application arterial system or the venous system. Nano-
was limited because it was bent and impaired the surgical nerve flap transfer (presented Japanese
blood circulation of each nerve piece, and the Society Reconstr Microsurg, Nov. 27, 2020.),
functional donor loss after sacrificing these which needs anastomosis of 0.1 mm feeding
nerves was not negligible. Bonney reported a vessels in nerve flaps, has also begun to be
vascularized nerve transfer of the ulnar nerve, a performed.
method that is performed only under specific
conditions of brachial plexus withdrawal injury,
where the ulnar nerve is a widely used trans- 7.5 Surgery for Lymphedema
planted nerve for nerve reconstruction of the
upper limbs. Therefore, the development of vas- Microscopic lymphatic vein anastomosis method.
cularized nerve transfer of the sural nerve, which In 1976, Melbourne plastic surgeon O’Brien
is mostly used as a transfer nerve by the conven- reported excellent results after microscopic lym-
tional method, has begun. After that, since the phatic venous anastomosis (LVA) [17–19].
donor site of the vascularized nerve flap having Yamada’s report is cited in his first treatise [20].
7 History of Reconstructive Microsurgery: From Myth to Reality 85
O’Brien is a pioneer in plastic reconstructive sur- feeding vessels attached to the normal lymphatic
gery who developed new tissue transplants one vessels. This is transplanted to the affected limb,
after another from the 1970s to the 1980s using and lymphatic fluid is guided to the venous system
microvascular anastomosis as well as lymph- by transfer of VL flap with normal function. In the
edema treatment. He then devoted his life to the case of hemilateral lower limb edema, a lymphatic
development and dissemination of surgical treat- vessel having a dynamic function in the contralat-
ment for lymphedema for 20 years. This method eral first metatarsal region is transplanted to the
was also used in Japan in the 1970s, but the post- inguinal region of the affected limb [25]. In cases
operative improvement rate was not as high as of bilateral lower limb edema, lymphatic vessels
expected. Therefore, there were few followers. I are collected from the axilla and transplanted into
often heard lectures on O’Brien’s lymphedema at the inguinal region. Since the smooth muscle of
the International Society of Microsurgery in the the VL flap is transplanted alive, the pumping
1980s and 1990s. His last lecture was in Vienna, function of the lymphatic vessels is restored and
but it was the most impressive. He had been treat- the lymphatic system is expected to have a perfu-
ing lymphedema so much, but no one had fol- sion effect. It is used for severe lymphedema, and
lowed lymphedema surgery. He cried and said some cases have begun to be completely cured.
that this was the hardest thing for him. He died
after that, but unfortunately, the technique disap-
peared in the world. Currently, a new super- 7.6 Nano-Microsurgery
microanastomosis technique is spreading all over
the world, within Japan as the transmission base. In 2017, Koshima moved from the University of
The background to this is that the real super- Tokyo to the International Center for
microvascular anastomosis was completed in Lymphedema of Hiroshima University Hospital
Japan from around 1990, and the introduction of and developed surgical instruments to perform a
new fundamental knowledge about the dynamic finer microvascular anastomosis of 0.1 mm. By
function of the lymphatic vessel was more effec- using this device and a 1.5–1.0 mm long needle
tive to popularize the technique of LVA [20]. of 40–30 μm, the vascular anastomosis for
Supermicro lymph venular anastomosis (LVA) 0.1 mm diameter became possible. Now a new
[21–24]. era of nanosurgery has been started.
The difference from the Yamada and O’Brien Reconstructive surgery expected from the intro-
is that the lymphatic vessels are perfused into the duction of this procedure includes artificial ana-
venous system by anastomosing the lymph ves- tomical changes (lymphatic vessel bypass, motor
sels just below the dermis with a needle of 0.3– and sensory nerve bypasses), anastomosis of
0.8 mm caliber size. nerve fibers (terminal branches), and cell mem-
Vascularized lymph channel transfer (VL brane incision to prevent diseases (prophylactic
transfer) with vascular pedicle [25]. bypass surgery). Now we can change or modify
In 2004, the first (VL transfer) of severe lymph- human anatomy. New operations such as nano-
edema of the lower limbs for which LVA was inef- surgical anastomosis and vascularized cellular
fective was performed at the University of Tokyo, transfer with feeding vessels are conceivable.
and 16 years later, it is currently completely cured
[25]. This procedure has been used for LVA-
ineffective severe lymphedema for the past References
16 years and has been shown to be very effective
in about 30%. This method has already been lec- 1. Komatsu S, Tamai S. Successful replantation of
tured and demonstrated internationally. For a completely cut-off thumb. Plast Reconstr Surg.
1968;42:374–7.
patients with severe lymphedema that has passed 2. Daniel RK, Taylor GI. Distant transfer of an island
for a long time, the lymp channel flap with prdicle flap by microvascular anastomoses. Plast Reconstr
vessels is collected from the healthy side with Surg. 1973;52:111–7.
86 I. Koshima
3. Song YG, Chen GZ, Song YL. The free thigh flap: a 15. Koshima I, Okumoto K, Umeda N, Moriguchi T, Ishii
new free flap concept based on the septocutaneous R, Nakayama Y. Free vascularized deep peroneal
artery. Br J Plast Surg. 1984;37:149–59. nerve grafts. J. Reconstr. Microsurg. 1996;12:131–41.
4. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy 16. Rose EH, Kowalski TA, Norris MS. The reversed
of the anterolateral femora flap. Plast Reconstr Surg. venous arterialized nerve graft in digital nerve recon-
1988;82:305–10. struction across scarred beds. Plast Reconstr Surg.
5. Koshima I, Fukuda H, Utsunomiya R, Soeda S. The 1989;83:593–602.
anterolateral thigh flap: variations in its vascular ped- 17. O’Brien MB, Sykes P, Threlfall GN, Browning
icle. Br J Plast Surg. 1989;42:260. FS. Microlymphaticovenous anastomoses for
6. Koshima I, Soeda S. Inferior epigastric skin flap obstructive lymphedema. Plast Reconstr Surg.
without rectus abdominis muscle. Br J Plast Surg. 1977;60:197–211.
1989;42:645–8. 18. O’Brien BM, Shafiroff BB. Microlymphaticovenous
7. Koshima I, Yamamoto H, Hosoda M, et al. Free and resectional surgery in obstructive lymphedema.
combined composite flaps using the lateral circum- World J Surg. 1979;3:3–15. 121-123
flex femoral system for repair of massive defects 19. O’Brien MB, Mellow CG, Khazanchi RK, Dvir E,
of the head and neck regions: an introduction to Kumar V, Pederson WC. Long-term results after
the chimeric flap principle. Plast Reconstr Surg. microlymphaticovenous anastomoses for the treat-
1993;92:411–20. ment of of obstructive lymphedema. Plast Reconstr
8. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi Surg. 1990;85:562–72.
musculocutaneous flap without muscle. Plast Reconstr 20. Yamada Y. The studies on lymphatic venous anas-
Surg. 1995;96:1608–14. tomosis in lymphedema. Nagoya J Med Sci.
9. Koshima I, Saisho H, Kawada S, et al. Flow-through 1969;32:1–21.
thin latissimus dorsi perforator flap for repair of 21. Koshima I, Kawada S, Moriguchi T, et al.
soft-tissue defects in the legs. Plast Reconstr Surg. Ultrastructural observation of lymphatic vessels in
1999;103:1483–90. lymphedema in human extremities. Plast Reconstr
10. Koshima I, Narushima M, Mihara M, Iida T, Gonda Surg. 1996;97:397–405.
K, Uchida G, Nakagawa M. New thoracodorsal artery 22. Koshima I, Inagawa K, Urushibara K, et al.
perforator (TAPcp) flap with capillary perforators for Supermicrosurgical lymphaticovenularanastomosis
reconstruction of upper limb. J Plast Reconstr Aesthet for the treatment of lymphedema in the upper extrem-
Surg. 2010;63:140–5. ities. J Reconstr Microsurg. 2000;16:437–42.
11. St Clair Strange FG. An operation for nerve pedicle 23. Koshima I, Nanba U, Tsutsui T, et al. Long-term
grafting. Br J Surg. 1947;34:423. follow-up after lymphaticovenular anastomosis
12. Taylor GI, Ham FJ. The free vascularized nerve for lymphedema in the legs. J Reconstr Microsurg.
graft. A further experimental and clinical application 2003;19:209–15.
of microvascular techniques. Plast Reconstr Surg. 24. Koshima I, et al. Minimal invasive lymphaticovenu-
1976;57:413–25. lar anastomosis under local anesthesia for leg lymph-
13. Koshima I, Harii K. Experimental study of vascular- edema. Is it effective for stage III and IV? Ann Plast
ized nerve grafts: multifactorial analyses of axonal Surg. 2004;53:1–6.
regeneration of nerves transplanted into an acute burn 25. Koshima I, Narushima M, Mihara M, Yamamoto T,
wound. J Hand Surg. 1985;10A:64–72. Hara H, Ohshima A, Kikuchi K, Todokoro K, Seki Y,
14. Koshima I, Harii K. Experimental study of vascu- Iida T, Nakagawa M. Lymphadiposal flaps and lym-
larized nerve grafts: morphometric study of axonal phaticovenular anastomoses for severe leg edema:
regeneration of nerves transplanted into silicone functional reconstruction for lymph drainage system.
tubes. Ann Plast Surg. 1985;14:235–43. J Reconstr Microsurg. 2016;32(1):50–5.
Evolution of Soft Tissue Flaps
Over Time
8
Geoffrey G. Hallock
Fig. 8.1 Oblique median forehead flap for two-stage repair of nasal tip
cism and geometric tissue rearrangements as be finally separated from the arm to complete
convenient. The first recorded evidence of the the nasal repair.
use of flaps can be traced to the forehead flap In both the Indian and Italian methods of nasal
(Fig. 8.1), circa 700 B.C., commonly used to reconstruction, the middle portion of the trans-
replace the tip of the nose that often had been ferred flap, which allowed reach to the defect,
removed as a corporal punishment as still done was always left open to the air, a technique today
in some parts of this world today. Although called an interpolation flap. Both of these flaps,
credit often is given to Susruta Samhita, the as were all of that time period, had no anatomi-
Kanghiara family from the Kangra District of cally identified blood supply, and so were called
the Northern India state of Himachal Pradesh by many “random flaps,” which they were.
may instead deserve this recognition, as secretly
such cutaneous flaps had been used there since
1000 B.C. [5]! More than 2 millennia later, Key Point
Gaspara Tagliocozzi [1597], often as he dis- In the beginning, most flaps were skin flaps
played in his Teatro Anatomico [anatomic the- designed by the individual surgeon depend-
ater] at the University of Bologna (Fig. 8.2), ing on what problem needed to be solved.
improved the Sicilian method of nasal recon- If the flap pattern worked, often some geo-
struction by cutting parallel slits in the skin metrical variation, the format could then be
over the biceps muscle to delay a bipedicled repeated with some reliability. These were
flap, one that remained attached to the arm only called “random flaps,” since cut at random
at both ends [6]. After a few weeks, the skin independent of any known blood supply,
was raised to be retained only at its most distal and often said to be nourished by a “sub-
connection on the arm, which allowed the rest dermal plexus” of vessels. Today, the
to be placed upon the nasal defect itself. Only proven existence of an intradermal plexus
after another few arduous weeks to allow neo- most likely is the true basis of circulation to
vascularization or new blood vessel growth into these random flaps.
the arm skin from the nose itself, the flap could
8 Evolution of Soft Tissue Flaps Over Time 89
Fig. 8.2 The anatomic theatre of Gaspara Tagliocozzi today at the University of Bologna
cal works, as were many others, were hidden aware that discrete vessels pierced the subcutane-
from the surgeons of the English-speaking world ous tissue to vascularize the skin, and by rumor, it
until recently [10, 11]. For that matter, the is said he placed in a drawing all the cutaneous
German physiologist Spalteholz [1893] [12] was perforators of the body, with suggestions of how
also presumably unaware of Manchot’s publica- flaps could be designed to incorporate them!
tion, when he concluded that the primary The trench warfare of the First Great War soon
circulation to the skin was either by direct cuta- overwhelmed the nascent plastic surgery spe-
neous arteries or reinforced by small indirect ves- cialty as did the onslaught of the tubed pedicle
sels that emerge through the deep fascia as spent flap (Fig. 8.5), persuasively disseminated world-
terminal branches, which had first supplied the wide by the New Zealander Gillies (17). This was
deeper tissues and that most often muscle—in a reasonable, if not naturally occurring event, by
fact retrospectively corroborating the findings of surgically closing side-to-side the raw undersur-
Manchot and then later Salmon! face of the unepithelialized open pedicle flaps
previously so commonly used [e.g., the forehead
flap] [17]. As in the Tagliacozzi method, the arm
Key Point or even the leg (Fig. 8.6) often served as the car-
Whenever one thinks that their personal rier for this flap from one body region to another,
discovery is a new revelation that will requiring sometimes multiple intermediate stages
change the course of reconstructive sur- and transfers to allow repeated neovasculariza-
gery, it is prudent to investigate the litera- tion until the final insetting, perhaps with months
ture as probably someone else had already between each step, and always subject to partial
conceived that idea, although perhaps not flap necrosis at any time. To minimize that risk,
in the same language. rigid length-to-width ratios were dogma to be
obeyed, which for example being no greater than
4::1 in the face, or 1::1 in the less well perfused
Unaware of these revelations by the anato- lower extremity (Fig. 8.7). Unfortunately, the
mists, the Italian surgeon Tansini [1896] [13] per- tubed pedicle was the classic “random flap,” rely-
sonally in his cadaver laboratories solved a ing as it could only on the “subdermal plexus” of
problem of reliably closing mastectomy wounds blood vessels, which represented a dead-end
by transfer of tissues available nearby from the divergence and simultaneously retarded the evo-
axillary region. He discovered there a large lution of the flap, as the anatomists were to prove
“scapular circumflex” blood vessel that coursed later once again that the surgeons had been
directly to the skin, but to be safe kept attached wrong.
the latissimus dorsi muscle to thereby conceive Slowly, if not slower, other options began to
the musculocutaneous flap (Fig. 8.4). Soon after- appear that proved to be more reliable and more
ward but now almost a century ago, Esser [1917] efficient than the tubed pedicle. Even the cos-
[14] in virtual anonymity raised flaps supplied by metic surgeon Jacques Joseph [1931] [18] in his
a palpable artery of the face, trunk, or even groin book on rhinoplasty included a description of a
that he could feel with his finger. He called these medial based deltopectoral flap from the upper
“biological flaps” or “artery flaps,” which were chest that captured the internal mammary muscu-
connected to the body only by their bare vascular locutaneous vessels at the second or third inter-
pedicle, known now as “island” flaps [15]. Esser costal space as its source of circulation,
did emphasize that inclusion of a nearby vein was information he had gleaned from Manchot’s trea-
as important if not more so than the artery, if tise that had depicted the same [8]! Bakamjian
venous congestion was to be avoided [15]—a [1965] [19] later wrote that this same deltopec-
problem still difficult to overcome with cutane- toral flap was based on “perforators” and could
ous flaps even today! Another contemporary, the be extended horizontally from the sternum to the
Italian surgeon Pieri [1918] [16], was also well shoulder to immediately allow reliable coverage
8 Evolution of Soft Tissue Flaps Over Time 91
Fig. 8.4 A musculocutaneous flap from the back whose vascular supply is from the axilla—the cutaneous branch of the
circumflex scapular to the skin, and the thoracodorsal vessels to the latissimus dorsi [LD] muscle
Fig. 8.5 Burned superior helix of the ear restored using icled”] to the neck transferred to the ear, and finally, after
the skin of the neck first rolled into a skinny tube, then at many more weeks, detached from the neck to complete
the second surgical step with one end still attached [“ped- the reconstruction
Fig. 8.6 Skin still attached [“pedicled”] to one leg trans- neovascularization, the original pedicle can be divided
ferred to cover the exposed bone of the other as a “cross- and the legs separated
leg” flap. After a month and development of sufficient
8 Evolution of Soft Tissue Flaps Over Time 93
Fig. 8.7 Calf flap remaining attached to the leg only on length of the page, so the length::width ratio is 1:2, which
one side like the page of a book for blood supply. The in the leg should be quite reliable
width of the base or flap pedicle is twice that of the raised
Key Point
A “free flap” or microvascular tissue trans-
fer, unlike a local or regional flap, is not
restricted in movement by its vascular ped-
icle. Instead, that can be severed, the tissue
transferred elsewhere, and then the circula-
tion reestablished after completion of
microsurgical anastomoses of both flap
artery and vein to those found at the new
recipient site. Note that briefly this tissue
has no blood supply, so in reality some
could appropriately consider a “free flap”
to be at least for a time a “microsurgical
graft.”
Fig. 8.14 The International Perforator Flap Faculty on site in Sydney, Australia
Key Point
Compound flaps have multiple tissue con-
stituents. If the latter are each dependent on
the other for circulation, this would be a
composite flap [e.g., a musculocutaneous
flap]. If consisting of multiple flaps, such a
combination if each flap were independent
of the other except for a common source
vessel would be called a chimeric flap. If
the flaps are not totally independent of each
other and have a common boundary, that
would be a conjoined flap.
Fig. 8.16 Hidehiko Yoshimatsu, major investigator of the
“pure skin perforator flap”
Fig. 8.18 Laurent Lantiere, Bohdan Pomahac, Eduardo D. Rodriquez, and Maria Siemionow, pioneers in facial vascu-
larized composite tissue allotransplantations
origin as Esser would have it, or manufactured and skillsets for the acquisition of the best new
via 3D printing. Obviously, the “future” will ideas that have sustained reliability, while
demand extensive research by the surgeon and always minimizing complications and untow-
anatomist alike until more pragmatic alterna- ard events for their patients—indeed realizing
tives become universally available. Until then that change is inevitable and the concept of
and surely long afterward, the surgeon must flaps will continue to evolve ad infinitum [53]
adapt and retain sufficient flexibility in mind (Fig. 8.19).
100 G. G. Hallock
perforator-thin
fasciocutaneous
perforator (thick)
anatomy and clinical implications. Plast Reconstr concept and designing safe flaps. Plast Reconstr Surg.
Surg. 2009;124(5):1529–44. 2011;127(4):1447–59.
32. Ger R. The technique of muscle transposition in the 44. Kimura N, Satoh K. Consideration of a thin flap as an
operative treatment of traumatic and ulcerative lesions entity and clinical applications of the thin anterolateral
of the leg. J Trauma. 1971;11(6):502–10. thigh flap. Plast Reconstr Surg. 1996;97(5):985–92.
33. Pontén B. The fasciocutaneous flap: its use in soft 45. Hong JP, Choi DH, Suh H, Mukarramah DA, Tashti
tissue defects of the lower leg. Br J Plast Surg. T, Lee K, Yoon C. A new plane of elevation: the
1981;34(2):215–20. superficial fascial plane for perforator flap elevation. J
34. Asko-Saljavaara S. Free style free flaps. Paper pre- Reconstr Microsurg. 2014;30(7):491–6.
sented at: programs and abstracts of the seventh con- 46. Hyakusoku H, Gao JH. The “super-thin ” flap. Br J
gress of the International Society of Reconstructive Plast Surg. 1994;47(7):451–64.
Microsurgery. New York. June, 1983. 47. Narushima M, Yamasoba T, Iida T, Matsumoto Y,
35. Song YG, Chen GZ, Song YL. The free thigh flap: a Yamamoto T, Yoshimatsu H, Timothy S, Pafitanis G,
new free flap concept based on the septocutaneous Yamashita S, Koshima I. Pure skin perforator flaps:
artery. Br J Plast Surg. 1984;37(2):149–59. the anatomical vascularity of the superthin flap. Plast
36. Wei FC, Jain V, Celik N, Chen HC, Chuang DCC, Reconstr Surg. 2018;142(3):351e–60e.
Lin CH. Have we found an ideal soft-tissue flap? An 48. Yoshimatsu H, Hayashi A, Yamamoto T, Visconti
experience with 672 anterolateral thigh flaps. Plast G, Karakawa R, Fuse Y, Iida T. Visualization of the
Reconstr Surg. 2002;109(7):2219–26. “intradermal plexus” using ultrasonography in the
37. Kroll SS, Rosenfield L. Perforator-based flaps for dermis flap: A step beyond perforator flaps. Plast
low posterior midline defects. Plast Reconstr Surg. Reconstr Surg Glob Open. 2019;7(11):e2411.
1988;81(4):561–6. 49. Hallock GG. The chimera flap: a quarter century
38. Koshima I, Soeda S. Inferior epigastric artery skin odyssey. Annal Plast Surg. 2017;78(2):223–9.
flap without rectus abdominis muscle. Br J Plast Surg. 50. Gordon CR, Siemionow M, Papay F, Pryor L,
1989;42(6):645–8. Gatherwright J, Kodish E, Paradis C, Coffman K,
39. Hallock GG. If based on citation volume, perforator Mathes D, Schneeberger S, Losee J, Serletti JM,
flaps have landed mainstream. Plast Reconstr Surg. Hivelin M, Lantieri L, Zins JE. The world’s experi-
2012;130(5):769e–71e. ence with facial transplantation: what have we learned
40. Wei FC, Jain V, Suominen S, Chen HC. Confusion thus far? Annal Plast Surg. 2009;63(5):572–8.
among perforator flaps: what is a true perforator flap? 51. Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current
Plast Reconstr Surg. 2001;107(3):874–6. principles of facial allotransplantation: the Brigham
41. Blondeel PN, Van Landuyt KH, Monstrey SJ, Hamdi and Women's hospital experience. Plast Reconstr
M, Matton GE, Allen RJ, Dupin C, Feller AM, Koshima Surg. 2013;131(5):1069–76.
I, Kostakoglu N, Wei FC. The “Gent” consensus on 52. Kantar RS, Ceradini DJ, Gelb BE, Levine JP,
perforator flap terminology: preliminary definitions. Staffenberg DA, Saadeh PB, Flores RL, Sweeney
Plast Reconstr Surg. 2003;112(5):1378–83. NG, Bernstein GL, Rodriguez ED. Facial transplanta-
42. Taylor GI. The “Gent” consensus on perforator flap tion for an irreparable central and lower face injury:
terminology: preliminary definitions [discussion]. a modernized approach to a classic challenge. Plast
Plast Reconstr Surg. 2003;112(5):1384–7. Reconstr Surg. 2019;144(2):264e–83e.
43. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The 53. Hong JP. Flaps, flaps, flaps: the evolution continues. J
anatomical (angiosome) and clinical territories of Reconstr Microsurg. 2014;30(7):441–2.
cutaneous perforating arteries: development of the
Flaps in Plastic Surgery
9
Joon Pio Hong and Jin Geun Kwon
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 103
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_9
104 J. P. Hong and J. G. Kwon
Constituents
Construction
Circulation
Direct vessel
Indirect vessel
Contiguity
Conformation
Conditioning
Fig. 9.1 Updated modified “atomic system” with “six mining flap nomenclature. (Reprinted with permission
Cs” of flap characteristics, but especially “core” or source from Hallock GG. The complete classification of flaps.
of flap circulation, where each has a distinct role in deter- Microsurgery. 2004; 24:157–161)
ous or can be endosteal, which usually provides a Constituents or composition classifies flaps
linear artery that runs for a considerable distance based on the composition of the flap (Table 9.1).
allowing greater vascular supply to the flap. A fasciocutaneous flap would be flap with deep
These vessels are usually named. The forehead fascia and all the structures above the deep fascia
flap based on the frontal branch of the superficial like the fat and the skin. Another example can be
temporal artery can be a good example. Indirect musculocutaneous flap, which is composed of
vessels can be myocutaneous or periosteal, where muscles, deep fascia, and all the structures above.
these are vessels stemming from the direct vessel The composition of the flap can include any tis-
source and reaching the flap by small perforating sues based on the reconstructive needs. The four
vessels. An example can be a musculocutaneous most commonly used flaps based on constituents
flap where the skin of the flap is being supplied are muscle/musculocutaneous flaps, fascia/fas-
by small vessels, which originated from a direct ciocutaneous flaps, perforator (skin with fat and
vessel and the branches piercing the muscle ulti- with and without fascia) flaps, and bone flaps,
mately reaching the flap. The flap elevation prac- which are further explained in the following
tice changed with the work of Taylor and Palmer sections.
presenting the angiosome concept increasing our
knowledge of vascular territory of the skin flap 1. Muscle and musculocutaneous flaps
[3]. Now, the concept of vascular territory has The muscle and musculocutaneous flaps
evolved from thinking of angiosome as the basic are widely used not only to resurface the
unit to applying the perforator as the basic unit defect but also to provide a functioning recon-
termed “perforasome” [4, 5]. struction. Thus, it is important to understand
106 J. P. Hong and J. G. Kwon
Table 9.1 The basis for flap classification (Reprint with on the pedicle). For example, a gastrocnemius
permission from Elsevier. From Hong JP. (2018) Flap
muscle flap can be used as a local flap to cover
classification and applications. In Neligan (eds) Plastic
Surgery) the lower knee defect but cannot reach the
1. Circulation (blood supply)
upper knee based on its pedicle. The most
Direct vessels commonly used Mathes–Nahai classification
Axial depicts the relationship between the muscle
Septocutaneous and its vascular pedicles: the regional source
Endosteal of the pedicle entering the muscle, the number
Indirect vessels and size of the pedicle, the location of the
Myocutaneous
pedicle with respect to the muscle’s origin and
Periosteal
2. Constituents (composition)
insertion, and the angiographic patterns of the
Skin (with subcutaneous fat) intramuscular vessels [6]. This classification
Fasciocutaneous/fascia helps the surgeons understand the vascularity
Muscle/musculocutaneous of each muscle flap ensuing the flap survival.
Visceral There are five different vascular patterns by
Nerve which the various muscles are categorized
Bone
(Fig. 9.2) [6]. Table 9.2 shows the typical
Cartilage
LN (with subcutaneous fat)
muscle flap examples for each type.
Other Type I: the muscles are supplied by a sin-
3. Contiguity (destination) gle vascular pedicle.
Local Type II: the muscles are supplied by both a
Regional dominant and minor vascular pedicle. The
Distant (free) larger dominant vascular pedicle will usually
4. Construction (flow)
sustain circulation to these muscles after the
Unipedicle*
Bipedicle
elevation of the flap with or without the minor
Anterograde* pedicles. This is the most common pattern
Retrograde (reverse) among muscle flaps.
Turbocharged Type III: the muscles have two large vascu-
Supercharged lar pedicles from separate vascular sources.
Arterialized venous These pedicles have either a separate regional
5. Conditioning
source of circulation or are located on oppo-
Delay
Tissue expansion
site sides of the muscle. Division of one pedi-
Prefabrication cle during flap elevation rarely results in loss
Sensate (sensory nerve) of muscle and can survive on one of its two
Functional (motor nerve) dominant vascular pedicles.
None* Type IV: the muscles are supplied by seg-
6. Conformation mental vascular pedicles entering along the
Special shapes
course of the muscle. Each pedicle provides
Tubed
circulation to a segment of the muscle, and
Combined flaps
None* division of the pedicles may result in segmen-
tal muscle necrosis.
Type V: the muscles are supplied by a sin-
the anatomy of these flaps as this will ensure gle dominant pedicle and secondary segmen-
better results not only in flap survival but to tal vascular pedicles. These muscles have one
understand the limitation of the flap, espe- large dominant vascular pedicle near the
cially when used as a local flap. When used as insertion of the muscle with several segmental
a local flap, the pedicle needs to be preserved pedicles near the origin and can survive on
having a limited reach (arc of rotation based either dominant or segmental pedicle allow-
9 Flaps in Plastic Surgery 107
Fig. 9.2 Mathes–Nahai classification for muscle and Extremity Wounds. In: Hollenbeck S., Arnold P., Orgill D.
musculocutaneous flaps (Reprinted with permission from (eds) Handbook of Lower Extremity Reconstruction.
Springer Nature. from Peredo A.L., Iorio M.L., Mathes Springer, Cham)
D.W. (2020) Principles of Local Muscle Flaps for Lower
ing the muscle to have a different rotation arc (Fig. 9.3) [1, 7]. Type A flap had multiple fas-
when done in a local flap. cial perforators that enter at the base of the
2. Fasciocutaneous flaps flap and extend throughout the longitudinal
A fasciocutaneous flap, originally called length. The flap can be based proximally, dis-
an axial flap, includes the skin, subcutaneous tally, or as an island. Type B flaps contained a
tissue, and underlying fascia. The vascular large, single septocutaneous perforator, which
supply is derived at the base of the flap from is large and relatively consistent. Type C flap
musculocutaneous perforators or direct septo- was based on multiple small perforators from
cutaneous branches of major arteries perforat- a source artery that needed to be included in
ing the deep fascia. Understanding the the flap. Type D is similar to Type C in that it
anatomy allows the surgeon to maximize the is based on multiple small perforators; how-
reconstructive result. Thus, based on the anat- ever, it is raised as an osteomyofasciocutane-
omy of the pedicle type when designed as a ous flap. The Mathes–Nahai classification is
local flap, the arc of rotation is determined by similar to Cormack and Lamberty’s classifica-
the extent of elevation of the deep fascia. The tion and is based on the type of deep fascial
point of rotation is based on the site of perforator (Fig. 9.4) [8]. Type A is a direct
entrance of the dominant vascular pedicle into cutaneous flap, in which the vascular pedicle
the fascia. There are multiple classifications travels deep to the fascia for a variable dis-
for this flap. The two most commonly used tance then pierces the fascia to supply the
classifications are the Cormack and Lamberty skin. Type B is a septocutaneous flap, which
classification and the Mathes–Nahai classifi- has a vascular pedicle that courses within an
cation. Cormack and Lamberty classified fas- intermuscular septum. Type C is a musculocu-
ciocutaneous flaps into four major types, taneous flap and is based on a vascular pedicle
differentiated by the origin of the circulation that is traveling within the muscle substance.
108 J. P. Hong and J. G. Kwon
Table 9.2 The classification for muscle flaps (Reprint Table 9.3 shows the examples of the fasciocu-
with permission from Elsevier. From Hong JP. (2018)
taneous flaps according to this classification.
Flap classification and applications. In Neligan (eds)
Plastic Surgery) 3. Perforator flaps
Type I vascular pattern muscles
Perforator flaps have evolved from muscu-
Abductor digiti minimi (hand) locutaneous and fasciocutaneous flaps with-
Abductor pollicis brevis out the muscle or fascial carrier. It was a
Anconeus natural evolution as reconstruction needed
Colon
Deep circumflex iliac artery
fine-tuning while aiming to minimize donor
First dorsal interosseous morbidities, as shown in Fig. 9.5. Note how
Gastrocnemius, medial and lateral unwanted tissues are discarded when only the
Genioglossus skin is needed based only on a single perfora-
Hyoglossus
Jejunum tor [9]. Thus, a perforator flap is a skin flap
Longitudinalis linguae (with or without fascia) based on a single per-
Styloglossus forator [10]. Like the angiosome concept
Tensor fascia lata showing the vascular territory of a source ves-
Transversus and verticalis linguae
Vastus lateralis sel, one must understand the anatomy and
Type II vascular pattern muscles physiology of a single perforator territory to
Abductor digiti minimi (foot) understand the limits and application for the
Abductor hallucis perforator flap [3]. The perforasome theory by
Brachioradialis
Saint-Cyr reported four major characteristics
Coracobrachialis
Flexor carpi ulnaris of a perforator flap: (1) each perforasome is
Flexor digitorum brevis linked with adjacent perforasomes by means
Gracilis of direct and indirect linking vessels; (2) flap
Hamstring (biceps femoris)
design and skin paddle orientation should be
Peroneus brevis
Peroneus longus based on the direction of the linking vessels,
Platysma which is axial in the extremities and perpen-
Rectus femoris dicular to the midline in the trunk; (3) filling
Soleus
of the perforasomes occurs within the perfora-
Sternocleidomastoid
Trapezius some of the same source artery first followed
Triceps by perforators of the other adjacent source
Vastus medialis arteries; and (4) vascularity of a perforator
Type III vascular pattern muscles found adjacent to an articulation is directed
Gluteus maximus
Intercostal away from that same articulation [4]. This
Omentum theory provides insights into perforator flap
Orbicularis oris vascularity and can clinically guide to harvest
Pectoralis minor a safer free or pedicle perforator flap [5]. In
Rectus abdominis
Serratus anterior 1989, Koshima and Soeda used the term “per-
Temporalis forator flaps” in their harvest for paraumbili-
Type IV vascular pattern muscles cal skin and fat island flap based on a muscular
Extensor digitorum longus perforator and now being applied all over the
Extensor hallucis longus
External oblique
body [9, 11, 12]. Although understanding the
Flexor digitorum longus anatomy and physiology is critical for perfo-
Flexor hallucis longus rator flaps, the classification was of less
Sartorius importance as the perforator flap concept was
Tibialis anterior
simplified through the freestyle and supermi-
Type V vascular pattern muscles
Fibula crosurgery concept [13–16]. The freestyle
Internal oblique approach identifies the perforator feeding the
Latissimus dorsi skin flap first and then dissect proximally
Pectoralis major
toward the source vessel, contrary to the clas-
9 Flaps in Plastic Surgery 109
a c
b d
Fig. 9.3 Cormack and Lamberty classification of fascio- Type C in that it is based on multiple small perforators but
cutaneous flaps differentiated into four types based on the raised as an osteomyofasciocutaneous flap (d). Reprinted
origin of the circulation. Type A flap had multiple fascial with permission from Springer Nature (Bianconi L.,
perforators that enter at the base of the flap and extend Pierotello L., Molteni G., Pellini R., Marchioni D. (2020)
throughout the longitudinal length (a). Type B flaps con- Anatomical Considerations of Free Flaps. In: Pellini R.,
tained a large, single septocutaneous perforator, which is Molteni G. (eds) Free Flaps in Head and Neck
large and relatively consistent (b). Type C flap was based Reconstruction. Springer, Cham. https://doi.
on multiple small perforators from a source artery, which org/10.1007/978-3-030-29582-0_2)
needed to be included in the flap (c). Type D is similar to
sical approach where identification of the cel while dissection [5, 15, 17]. One form of
source vessel was made first and then dissec- perforator based local flap, the propeller flap,
tion toward the perforator. This allows the is an island flap that reaches the recipient site
freedom to design flaps based on any perfora- through an axial rotation [18, 19]. When a
tor as well as alleviate the risk for pedicle perforator propeller flap is being elevated, the
variation [14]. The supermicrosurgery perforator is dissected free from the fascial
approach, perforator-to-perforator anastomo- and fat adhesions to minimize the chance of
sis, allows harvesting the flap as a short pedi- kinking. Although less rotation reduces the
cled flap reducing the dissection time and chance for kinking, the skin island may be
minimizing the risk for traumatizing the pedi- safely rotated up to 180 degrees (Fig. 9.6).
110 J. P. Hong and J. G. Kwon
Muscle
Septum
c TYPE C - Musculocutaneous
Muscle
Fig. 9.4 Mathes–Nahai classification for fasciocutane- Type C is a musculocutaneous flap and is based on a vas-
ous flaps. Type A is a direct cutaneous flap, in which the cular pedicle that is traveling within the muscle substance
vascular pedicle travels deep to the fascia for a variable (c). Reprinted with permission from Springer Nature
distance and then pierces the fascia to supply the skin (a). (OBrien M. (2009) Fundamentals of Plastic Surgery. In:
Type B is a septocutaneous flap, which has a vascular Plastic and Hand Surgery in Clinical Practice. Springer,
pedicle that courses within an intermuscular septum (b). London. https://doi.org/10.1007/978-1-84800-263-0_1)
Advancement flap
Rotation flap
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Fig. 9.8 A keystone flap essentially being two V–Y advancement flaps along the long axis of the flap
main vascular source to connect to an additional tissue, and other tissues such as nerve, tendon,
pedicle from the same flap creates a direct flow to and bone that uses a subcutaneous vein for the
the vascular territory of the connected branch) arterial inflow and venous outflow (Fig. 9.12)
(Fig. 9.11) [28, 29]. The last category in this clas- [30]. Unlike the classical flap where a pedicle is
sification of construction (flow) is arterialization composed of artery and vein, this flap does not
of vein to supply flow to the flap. A venous flap is require to include an artery within the flap but
defined as a composite flap of skin, subcutaneous rather has multiple superficial veins, of which
114 J. P. Hong and J. G. Kwon
A Va Ve V
the groin and also can provide vascular infor- warming to minimize hypothermia (which
mation of the donor flap facilitating the plan- may decrease peripheral blood flow), and deep
ning and the surgical procedure [61, 62]. While vein thrombosis prophylaxis, and an intensive
the CT angiogram gives overall information of glucose control for diabetes is needed to
the vascular layout, the ultrasound may provide ensure a positive outcome [58]. One should be
real-time information on donor and recipient flexible to change in the initial design of the
vessels such as the caliber of the pedicle, the approach as unforeseen events frequently
intramuscular course of the pedicle, location of occur. When insetting the flap, tension must
the corresponding flap, and the subcutaneous be avoided, especially around the vascular
branching from the pedicle [59, 63, 64]. The pedicle. Meticulous coagulation of the flap as
handheld Doppler allows to simply and quickly well as the recipient bed is crucial to minimize
gather information about the perforator and the hematoma after surgery. A closed suction
main axial vessels. However, it may lack drain system is generally used at both the
detailed information such as the course of the donor and recipient closure sites.
perforator, and the actual positive finding may • Postoperative Management
not correlate clinically. Nevertheless, handheld Postoperative flap management is of equal
Doppler remains the first tool to gather infor- importance to the success of a reconstruction.
mation regarding the pedicle of the flap. The maintenance of proper positioning, tem-
Flap selection should be based on the ele- porary immobilization, and proper dressing of
vator reconstruction concept addressing the the wound are critical. Pressure on the flap
need of the defect and the ultimate functional base is to be avoided during the postoperative
and esthetic outcome. Perforator flaps can be period. Continued use of postoperative antibi-
selected by factors such as the dimension of otic therapy should be based on wound cul-
the flap, the length of the pedicle, composition tures and selection of culture-specific
of the flap, thickness of the flap, and the antibiotic agents [68]. Patient-specific ambu-
patient position during operation [65]. Donor lation should be planned, avoiding unneces-
site morbidity should also be considered when sary bed rest. Postoperative monitoring of a
selecting a flap. When possible, the donor site flap is critical to discover any problem with
should be closed directly to preserve form. the anastomosis early enough to salvage the
Use of a flap that requires a skin graft for flap [5]. Clinical observation generally
donor site closure is justified when the flap involves assessment of skin color, tissue tur-
harvested is clearly superior to alternate flaps gor, temperature, capillary refill, and pinprick.
for the defect. Finally, for the preoperative The ideal monitoring measure should be reli-
planning, the surgeon should always think of a able, reproducible, sensitive, cost-effective,
plan B flap [5]. This allows preoperative visual user-friendly, and continuous [58].
practice, reduction of surgical time, minimiz-
ing unwanted variables, and maintaining the
high spirit of motivation [66, 67]. 9.6 Clinical Cases
• Intraoperative Techniques
When possible, the patient is positioned to Case 1. A 55-year-old male patient had a traffic
allow visualization of both donor and recipi- accident that ended in a tibia bone infection with
ent sites. This allows a two-team approach and soft tissue defect of the right leg (Fig. 9.14). The
does not need additional surgical time to defect showed a tibial bone defect of 10 cm with
change the patient’s position during operation. skin loss (A). Evaluating the vascular status, both
For surgeries expecting long operating time, anterior and posterior tibial vessels were intact
careful padding of potential pressure sites to (B). Complete debridement of bone and soft tis-
avoid injury to normal structures, active sue was performed prior to reconstruction. The
9 Flaps in Plastic Surgery 119
a b
Fig. 9.14 A 55-year-old male patient had a traffic acci- the peroneal vessels was planned. The flaps were prefabri-
dent that ended in a tibia bone infection with a soft tissue cated into a combined chimeric flap by anastomosing the
defect of the right leg (a). Evaluating the vascular status, peroneal vessels to one of the branches of the descending
both anterior and posterior tibial vessels were intact (b). branch of the lateral femoral circumflex vessel (c). The
An anterolateral thigh perforator flap based on the immediate postop is shown (d). The patient follow-up at
descending branch of the lateral femoral circumflex vessel 4 years presents a well-healed bone and soft tissue allow-
combined with a contralateral fibular bone flap based on ing the patient to ambulate without any assistance (e)
120 J. P. Hong and J. G. Kwon
a b c
Fig. 9.15 A 32-year-old male patient with chronic osteo- After advancing the flap to cover the defect, a skin graft
myelitis of the right tibia is presented with a skin defect was performed over the donor site (b). At 1 year after the
and a small bone defect after debridement. A random local operation, the flap is covering the tibial without any fur-
bipedicled flap was designed adjacent to the defect (a). ther bone infections (c)
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flow temporal artery island flap. Clin Plast Surg. crush avulsion amputations of the forearm. Injury.
1976;3(3):441–5. 2019;50(Suppl. 5):S105–S10.
26. Matthews RN, Fatah F, Davies DM, Eyre J, Hodge 43. Ueda K, Oba S, Nakai K, Okada M, Kurokawa N,
RA, Walsh-Waring GP. Experience with the radial Nuri T. Functional reconstruction of the upper and
forearm flap in 14 cases. Scand J Plast Reconstr Surg. lower lips and commissure with a forearm flap com-
1984;18(3):303–10. bined with a free gracilis muscle transfer. J Plast
27. Almeida MF, da Costa PR, Okawa RY. Reverse- Reconstr Aesthet Surg. 2009;62(10):e337–40.
flow island sural flap. Plast Reconstr Surg. 44. Hallock GG. Simplified nomenclature for compound
2002;109(2):583–91. flaps. Plast Reconstr Surg. 2000;105(4):1465–70.
28. Semple JL. Retrograde microvascular augmenta- quiz 71-2
tion (turbocharging) of a single-pedicle TRAM flap 45. Hallock GG. Further clarification of the nomenclature
through a deep inferior epigastric arterial and venous for compound flaps. Plastic and reconstructive sur-
loop. Plast Reconstr Surg. 1994;93(1):109–17. gery. 2006;117(7):151e-60e.
29. Yamamoto Y, Nohira K, Shintomi Y, Sugihara T, 46. Hallock GG. Simultaneous transposition of ante-
Ohura T. "Turbo charging" the vertical rectus abdomi- rior thigh muscle and fascia flaps: an introduc-
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tion of extensive chest wall defects. Br J Plast Surg. 1991;27(2):126–31.
1994;47(2):103–7. 47. Belousov AE, Kishemasov SD, Kochish AY, Pinchuk
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by arterial inflow through the venous system: an tic and reconstructive surgery. Ann Plastic Surg. 1993,
experimental investigation. Plast Reconstr Surg. 31(1):47–52. discussion−3
1981;67(3):328–34. 48. Gottlieb LJ, Krieger LM. From the reconstructive lad-
31. Myers MB, Cherry G. Mechanism of the delay phe- der to the reconstructive elevator. Plast Reconstr Surg.
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32. Abbase EA, Shenaq SM, Spira M. el-Falaky 49. Pluvy I, Panouilleres M, Garrido I, Pauchot J, Saboye
MH. Prefabricated flaps: experimental and clinical J, Chavoin JP, et al. Smoking and plastic surgery,
review. Plast Reconstr Surg. 1995;96(5):1218–25. part II. Clinical implications: a systematic review
33. Morris SF, Taylor GI. The time sequence of the with meta-analysis. Annales de chirurgie plastique et
delay phenomenon: when is a surgical delay effec- esthetique. 2015;60(1):e15–49.
tive? An experimental study. Plast Reconstr Surg. 50. Fischer JP, Nelson JA, Sieber B, Cleveland E, Kovach
1995;95(3):526–33. SJ, Wu LC, et al. Free tissue transfer in the obese
34. Neumann CG. The expansion of an area of skin by patient: an outcome and cost analysis in 1258 con-
progressive distention of a subcutaneous balloon; use secutive abdominally based reconstructions. Plast
of the method for securing skin for subtotal recon- Reconstruct Surg. 2013;131(5):681e–92e.
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1957;19(2):124–30. Microsurgery. 1995;16(6):396–9.
35. Kenney JG, DiMercurio S, Angel M. Tissue-expanded 52. Davison SP, Kessler CM, Al-Attar A. Microvascular
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Burn Care Rehabil. 1990;11(5):443–5. lability. Plast Reconstr Surg. 2009;124(2):490–5.
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53. Khouri RK, Cooley BC, Kunselman AR, Landis JR, 61. Duymaz A, Karabekmez FE, Vrtiska TJ, Mardini
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54. Endara M, Masden D, Goldstein J, Gondek S, in the posttraumatic setting. Plast Reconstr Surg.
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Microsurgical Procedures in Plastic
Surgery
10
Filippo Marchi and Fu-Chan Wei
Key Points
• Spend time getting the position right,
making sure that the interpupillary dis-
tance and diopter correction are right.
• Focus should be adjusted with the scope
at the highest magnification before
starting.
10.1.2 Microsurgical Instruments Fig. 10.2 Surgical loupes (magnification rate 3.5, focal
distance 420 mm)
The microsurgical instrumentation is extensive,
but in clinical practice, the essential devices for small set, which includes forceps, needle holders,
the execution of procedures are limited and most scissors, vascular dilators, free micro clamps, and
surgeons become proficient with a reasonably approximators.
10 Microsurgical Procedures in Plastic Surgery 127
a b
c d
e f
Fig. 10.3 Basic microsurgical set of instruments. (a) Needle holder, (b) short forceps, (c) long forceps, (d) scissors, (e)
vessel dilator, and (f) double approximator clamp
The basic requirements of microsurgical limited tissue reactions. The most commonly
instruments are handling, precision, and delicacy used wires are 9–0, 10–0, and 11–0 (from 26 to
in grasping tissues. Handling depends on the 18 μm in diameter); 3/8 circle needles can have
shape and weight of the tool. The shape may also different sections—the length of the 10–0 needle
vary: flat shape is recommended for forceps and is approximately 3.8/4 mm. Those with a cylin-
dilators, while curved shape may be preferable drical section are less traumatic for vascular and
for scissors and needle holders that require subtle nerve walls in order to minimize the interference
rotational movements. The weight of the micro- with surrounding tissues. The needles with a tri-
surgical instrument must be correctly distributed angular tip have greater ease of entry into the
in order to maintain the center of gravity included more resistant tissue but are not widely used. In
in the space between the thumb and index finger general, the needle used in the vascular suture
of the operator’s hand (Fig. 10.3). must not have a greater size than the suture in
order not to damage the vessel wall during the
passage [2].
Key Points
• All instruments need to be in excellent
working condition.
• Instruments tip shall not touch another
10.2 Lifestyle and Ergonomics
hard object.
To obtain good and consistent results, ergonomic
shrewdness is necessary, such as correct and
comfortable positioning, with the aim of reduc-
10.1.3 Sutures ing tiredness, discouragement, and tremors. The
length of the operations (often several hours) and
The most used sutures in microsurgery are nylon the need to maintain the same position can cause
or polypropylene. These have a smooth surface, low back pain, neck pain, and more [3]. Only
allow for easy closure of the knots, and generate through constant practice can one become famil-
128 F. Marchi and F.-C. Wei
iar with microsurgery, improving the refinement application of microsurgery ranges from trauma
of the senses, the perception of depth of field, of the limbs, brachial and cervical plexus inju-
sensory feedback, and proprioception. ries, reimplantation, and facial nerve reanimation
Tremor has a negative impact on the quality of after tumor ablation of congenital diseases.
the micro-surgical gesture with the consequent The basic principles of microsurgical manage-
possibility of error and damage to the tissues. ment of nerve injuries are the following: quanti-
Physiological tremor can be amplified by muscle tative preoperative assessment of the residual
fatigue, excessive effort, anxiety, cold, hunger, function, adequate debridement nerve stumps to
the use of stimulants, the use of alcoholic bever- healthy nerve fibers to allow nerve regeneration
ages, or metabolic oscillations or to proceed across the repair area, and nerve repair
hyperthyroidism. in a tension-free manner under magnification;
The surgeon must be well seated with the head when a tension-free direct repair is not possible,
slightly flexed (about 30°), the back must be other techniques are used for reconstructing the
straight, the arms must be resting, the forearms nerve gap with nerve grafts or nerve transfers.
must be well supported up to the wrists and ulnar Where primary repair is not optimal (in cases
edge of the hand, the feet must be stable on the with a severe crush, stretch, or loss of nerve
ground. The chair and table must be adequate to tissue), delayed repair approximately 3 weeks
assume a correct position. The distance between postinjury is advisable. Depending on the type of
the surgical field and the microscope eyepieces lesion, the size of the nerve trunk, and the three-
should correspond to the vertical distance dimensional structure of the nerve, different
between the surgeon’s hands and eyes (on aver- suturing techniques can be used. The simplest
age 20–25 cm). Microsurgical instruments must suture is the end-to-end neurorrhaphy in which
be held like a pen with the tip of the thumb, index, two nerve stumps connect. This type of suture is
and middle fingers at a distance of 3.5–4 cm from divided into epineural, perineural (or fascicular),
the tip of the instrument. and epi-perineural. The term lateral neurorrhaphy
refers to connecting a nerve stump with an intact
nerve segment after creating an epineural win-
Tips and Tricks
dow; it is a procedure with more restricted indi-
Familiarize with microscope
cations. Nerve anastomosis should be performed
Feet flat on the ground to provide a sta-
with either 9–0 or 10–0 nylon, interrupted
ble base
sutures. The stumps must be prepared sharply
Upper extremities well supported to
using either a sharp blade or a straight microscis-
minimize fatigue and tremor
sor to achieve a clean cut.
Three points of stabilization while hold-
Finally, postoperative management is funda-
ing instrument: elbow, wrist, and last 3
mental to optimize the outcome; occupational
fingers
and physical therapy is performed to maintain
range of motion and sensory and motor
re-education.
10.3 Categories of Microsurgery
The ability of peripheral nerves to regenerate Known also as microvascular surgery, it is the
their axons and reinnervate their targets after main branch of microsurgery that allows con-
injury depends much on nerve coaptation accu- necting arteries and veins of a small caliber (from
racy. The timing of the repair, the type and extent 1 over even smaller). Microvascular surgery
of the injury, and patient features also contribute stands for the widest field of application of
to the outcome after nerve injury [4]. The field of microsurgery, and autologous free tissue transfer
10 Microsurgical Procedures in Plastic Surgery 129
(named free flap) is one of its most frequent techniques can be utilized: direct end-to-end and
application [5]. Success in microvascular surgery end-to-side, utilizing continuous suture, inter-
is multifactorial, with technical skills in vessel rupted suture, or loops [6]. The choice depends
anastomosis as the first step on the road. Another on the orientation, the vessel’s size, and the pre-
important factor in ensuring success is the use of ferred technique of each surgeon [7]. Patency
healthy recipient vessels of appropriate size with should be assessed after the completion of each
good outflow. A healthy vessel has a soft wall and anastomosis. This can be done by simple obser-
a vascular sheath that can be easily dissected, vation or by conducting a patency test. A sign of
while traumatized vessels may be encased in patency of the artery includes good flow from the
fibrotic tissue. The dissection of the vascular ped- vein. If the recipient vein fills well and has a natu-
icle proceeds under magnification to free suffi- ral round diameter, it is likely to be patent. If it is
cient length to allow a tension-free anastomosis. engorged and the blood column is darker than
Gross trimming of the adventitia is performed that in the recipient vessel, it is thrombosed and
around the area of the anastomosis, allowing suf- will require to do the anastomosis again. Empty
ficient length of the trimmed vessel for applica- and refill should only be performed when needed
tion of the vascular clamp. [8]. After completing the anastomosis, should be
It is vital to check the flow within the artery. checked possible leaks. If a small amount of
Expansile pulsation of the artery usually indicates blood leaks temporarily from the sutures’ hole,
adequacy but should be confirmed by healthy no more sutures are needed to seal the anastomo-
spurting from the divided vessel. If a healthy- sis; however, if the spurt is from the suture line,
looking vessel does not spurt well, check that the additional stitches are required. Because of tech-
patient is normotensive. The ideal recipient vein nological advances, reconstructive microsurgery
should be at least as wide as the donor vein; oth- has reached the stage where anastomosis of ves-
erwise, it may produce a bottle-neck effect and sels as small as 0.3 mm is feasible. This type of
compromise drainage. The vein is divided to microsurgery, called as “supermicrosurgery,” is
assess its quality, and good backflow from the now applied for “perforator-to-perforator” flaps
vein indicates a fairly health vessel. The vessels and complex digital replantation.
should be irrigated during and after dissection
with heparinized saline, and on completion of the
dissection, covered with 2–4% lidocaine or 3% 10.4 Pictures of Microvascular
papaverine-soaked gauze pieces to prevent desic- Anastomosis
cation and vasospasm. The vessel ends to be
anastomosed are placed in a double approximat- 10.4.1 Microlymphatic
ing clamp under microscope magnification. This
allows the vessels to be manipulated so that the Lymphedema, due to congenital diseases, infec-
lumen and intima of both ends can be clearly tions, or iatrogenic insults, refractory to nonsurgi-
visualized, to compare the caliber, and eventually cal therapies, may be managed by surgical
to adjust it with different refinements. A sudden treatment. From simple excision to advance
change of caliber may cause turbulence that microsurgical techniques, a variety of surgical
might lead to thrombosis. Pliable nonadherent modalities have been shown to improve, and
and nonreflective background material is placed sometimes reverse, the devastating effects of this
under the vessels. Moistened gauze pieces are disease. Indications include insufficient lymph-
placed around the vessel to prevent the suture edema reduction by well-performed medical and
from adhering to surrounding structures and to physical therapy, recurrent episodes of lymphan-
position adequately the clamp. Good hemostasis gitis, intractable pain, and worsening limb func-
should be maintained at all times. The vessel tion. The first microsurgical technique described
lumens may need gentle dilatation with a vessel is the so-called “derivative operation,” which con-
dilator or microneedle holder to increase the size nects lymph nodes to veins. This has been largely
and to prevent vasospasm. Different anastomotic abandoned except in endemic areas of lymphatic
130 F. Marchi and F.-C. Wei
a b
c d
Fig. 10.4 Isolated thumb amputation at distal phalanx around flap (yellow arrows: nerves; red arrow: artery; blue
reconstructed with a modified great toe wrap-around flap. arrow: vein). (c) Immediate view after toe transfer and
(a) Preoperative picture. (b) Harvested great toe wrap- revascularization. (d) Appearance 1 year postoperation
warm and 12 h cold for the hand and proximal ment and early coverage in trauma, replacing
amputation [13](Fig. 10.4). lost functional units in cancer ablation, vascu-
larity improvement in the ischemic leg, and pro-
viding a stable contact surface for trophic ulcers.
10.6 Multidisciplinary Flaps with different tissue components (com-
Applications pound and composite), including skeletal, ten-
don, muscle, vessel, and nerve, help to restore
10.6.1 Orthopedics function and play a critical role in limb salvage
(Fig. 10.5).
Across the last few decades, microsurgery has
made elemental contributions to orthopedics in
restoring anatomy and function after traumatic 10.6.2 Neurosurgery
injury or for congenital malformations. Fifty
years ago, microsurgical composite tissue trans- Microsurgery allows to restore the blood supply
fer became a reality, with functioning of free to the brain through extracranial–intracranial
muscle transfers, vascularized bone grafts, toe- revascularization, especially in the presence of
to-hand transfers, and so on. Microsurgical tech- complex unclippable aneurysms, occlusive cere-
niques have become an integral part of orthopedics brovascular disease, or in skull base tumor sur-
and hand surgery; these applications of microsur- gery involving major vessel sacrifice, a scenario
gery are also named “orthoplastic surgery.” associated with risk of ischemic complications in
Therefore, limb salvage surgery became the ∼20% of patients [14, 15].
choice of treatment over amputation in many Several bypass options are available; in the-
cases. It embraces procedures such as debride- ory, cerebral bypass can be classified as low flow
132 F. Marchi and F.-C. Wei
a b
Fig. 10.5 Compound tibia and coverage defect reconstructed with a fibula osteoseptocutaneous flap. (a) Preoperative
view. (b) Harvested fibula osteoseptocutaneous flap. (c) Appearance of reconstruction site 10 years postoperation
(15–25 mL/min), medium flow (40–70 mL/min), components (i.e., muscle, fascia, skin, and bone).
and high flow (70–140 mL/min) [16]. Microsurgery provides a broad spectrum of
Another contribution of microsurgery regards options to cover and restore such a complex ana-
the reconstruction of scalp defects. Neurosurgical tomical area.
approaches often require extensive scalp dissec-
tion, bone fixation, and tissue destruction. Thus,
hardware exposure, bone necrosis, soft tissue 10.6.3 Head and Neck Surgery
infection, which lead to a significant amount of
tissue loss, are commonplace. Free soft tissue Major ablative surgeries for cancer or trauma of
flaps provide an effective treatment for such the head and neck region can be devastating for
conditions. the patient. Indications in the surgical manage-
Cancers of the paranasal sinuses, nasal cavi- ment of head and neck tumors have been pushed
ties, and lateral skull base nowadays are forward due to the development of a wide variety
approached mostly surgically. Endoscopic and of reconstructive options.
open approaches to the anterior and lateral skull To restore form and function and to achieve
base nowadays are standard procedures. Defects total rehabilitation of the patient require recon-
involving the skull base require multiple tissue struction of anatomic defects to obtain aesthetic
10 Microsurgical Procedures in Plastic Surgery 133
appearance and physiologic function. Thus, two multidisciplinary approach required in modern
primary goals need to be addressed in reconstruc- medicine (Figs. 10.6 and 10.7).
tive surgery: aesthetic and functional restoration.
With the advent of microsurgery and free flaps,
we approached a new era in reconstructive sur- 10.6.4 Ophthalmology
gery, which allows the reconstruction of previ-
ously unreconstructable defects. Consequentially, Microsurgical techniques contribute to a niche of
more complex wounds were created through ophthalmology in providing the restoration of
more radical surgery, for which, in the past, a corneal sensation after denervation. The normal
suboptimal reconstruction was considered the corneal sensation is essential for corneal func-
standard of care. However, since the ideal recon- tion; it initiates blink reflex in response to heat,
struction is based on the “like-with-like” concept, evaporation, and pain; it also stimulates normal
the description of vascularized bone transfers epithelial cell mitosis and migration, maintaining
wedged the modern era of mandibular recon- surface integrity. Corneal anesthesia is a devas-
struction. The turning point in the early 1990s tating condition, causes a decrease in lacrimal
was the introduction of the fibula osteoseptocuta- gland secretion, and induces loss of the trophic
neous flap for mandible reconstruction [17, 18] elements supplied by the nerves to maintain
and the perforator flaps such as the anterolateral appropriate epithelial function. The denervation
thigh flap [19]. Furthermore, it reached its peak leads to neurotrophic keratitis, and the corneal
with the refinement and the flexibility of the free- surface becomes vulnerable. Corneal neurotiza-
style approach to restore complex, tridimensional tion is a revolutionary technique that can offer a
defects, maintaining the benefits of a two-team potential cure to eyes with neurotrophic keratop-
approach [20]. athy. Corneal neurotization is a revolutionary sur-
Examples of reconstructive attempts to restore gical procedure in which a donor nerve graft is
the facial aesthetic include restoration of contour, coapted to the damaged nerve. The technique
appearance, and expression of the face. relies on a transfer of a healthy nerve segment to
Rehabilitation of oral competence also is neces- the corneo-limbal area and restores the basis for
sary for defects of the oral cavity, oropharynx, sub-basal plexus regeneration and hence the
and lips. Examples of functional restoration reversal of the neurotrophic disease [21]. Corneal
include speech, mastication, dentition, and deglu- reinnervation can be performed by direct nerve
tition. Soft tissue loss may be due to loss of the transfers or by nerve graft interpositions. Terzis
cutaneous or mucosal lining or the bulk of under- et al. introduced the first neurotization procedure
lying soft tissues, or the combination of all. to treat unilateral facial nerve palsy patients [22].
Ideally, all bone losses should be replaced with They mobilized the contralateral supratrochlear
bone. However, the need for bone reconstruction nerve at its proximal end near the orbital rim and
is dictated by a decision-making process based redirected it under the nasal bridge and through a
on several factors (patient condition, prognosis, crease blepharotomy into the conjunctiva. The
quality of life, etc.) as well as on the site and nerve’s endoneurium was opened, and the fasci-
extent of bone resection, whether it is in the man- cles were separated and sutures in conjunctival
dible, maxilla, or calvarium. Besides, the plan- pockets near the limbus. Because direct neuroti-
ning of reconstructive surgery requires assessment zation is an extensive procedure, sometimes
of tissue loss, which may be from mobile parts of interposition nerve graft is needed. Elbaz et al.
the anatomy of the head and neck region or from introduced the use of sural nerve grafts to con-
immobile tissues. Special thought is necessary nect to the contralateral supratrochlear or supra-
for reconstruction of resected nerves, blood ves- orbital nerves to the perilimbal region [23].
sels, cartilage, or any combination of these tis- Corneal sensory recovery is expected at 6 months
sues. Head and neck reconstructive microsurgery after the procedure. The physiological mecha-
is one of the most representative of the modern nisms of nerve regeneration are still to be
134 F. Marchi and F.-C. Wei
a b
c d
Fig. 10.6 Right tongue squamous cell carcinoma receiv- (b) Design of an anterolateral thigh flap. (c) Harvested
ing hemiglossectomy and radical neck dissection and anterolateral thigh perforator flap. (d) Appearance 3 years
reconstruction with an anterolateral thigh perforator cuta- postoperation
neous flap. (a) Preoperative view of right tongue cancer.
e lucidated: direct sprouting versus neurotrophic Despite the improvements, hepatic artery
stimulus [24]. reconstruction is still the most pivotal and chal-
lenging step in the implantation of the new graft
from living donor. Microsurgical repair of the
10.6.5 General Surgery hepatic artery decreased the complications and
failure rate [25] (Fig. 10.8).
Microsurgery is mostly applied in two fields in
general surgery: breast reconstruction after tumor
ablation and liver transplantation. 10.6.6 Gynecology/Urology
Reconstruction after mastectomy is often
required by women with breast cancer who are not Genital reconstruction can be classified into con-
eligible for conservative therapy and women with genital and acquired.
a high genetic risk for breast cancer. Current breast For phalloplasty, the radial forearm free flap
reconstruction techniques are diverse and may stands as the gold standard technique. Transferring
involve the use of an autologous tissue flap, a pros- tissue, including the radial artery, vena comitans,
thetic implant, or both. The deep inferior epigas- cephalic vein, and lateral and medial antebrachial
tric artery (DIEP) and the profunda femoral artery cutaneous nerves, from the forearm, became pos-
perforator (PAP) flap are two workhorse flaps. sible to reconstruct the penis and urethra. This
Liver transplantation is now considered the flap enables single-stage reconstruction of a sen-
standard treatment of end-stage liver disease. sate phallus and glans. Phalloplasty is a complex
10 Microsurgical Procedures in Plastic Surgery 135
a b
c d
e f
Fig. 10.7 Mandibular ameloblastoma receiving segmen- dibular ameloblastoma. (c) Inset and fixation of the
tal mandibulectomy and simultaneous reconstruction with transferred fibula in the defect site. (d) Intraoral scan after
a fibula osteoseptocutaneous flap, osteointegration teeth osteointegration teeth implantation. (e) Intraoperative
implantation, and dental prosthesis on the same day. (a) placement of temporary dental prosthesis. (f) Appearance
Central mandibular defect after segmental mandibulec- 18 months after postoperation
tomy and reconstruction plate fixation. (b) Resected man-
procedure that, in some individuals, can help reconstructive surgery, particularly from an often
alleviate gender unease [26]. overlooked, cosmetic standpoint. Several
Vulvovaginal reconstruction for congenital techniques have been described from simple
defects remains one of the most challenging in serial dilations to complex flaps (such as flaps
136 F. Marchi and F.-C. Wei
a b
c d
Fig. 10.8 Preoperative condition of patients previously treated for right breast cancer (a). Recipient site pocket dissec-
tion (b). Deep inferior epigastric perforator flap (DIEP) dissection (c). Breast reconstruction 1 year follow-up (d)
from the groin or the thigh) and intestinal pedi- donor, proving the concept for treating infertility
cled flaps. by transplantation from a deceased donor, open-
On the other hand, reconstruction of vulvar ing a path to healthy pregnancy for women with
acquired defects aims to reestablish the anatomy uterine infertility, without the need of live donor
of the external genitalia, ensuring the presence of surgery [28].
a wide orifice for the vagina and improving body
image by allowing also the restoration of micturi-
Key Points
tion and defecation functions. Over the last
Patient factors
decades, a variety of reconstructive procedures
have been validated. However, the ideal flap does • Cardiac and respiratory functions should
not exist yet [27]. be optimized before free tissue transfer.
Lastly, in the past years, uterus transplantation • Age, in itself, is not a contraindication
from live donors became a reality to treat infertil- for free-flap as long as the patient is in
ity. Afterward, it was performed using a deceased
10 Microsurgical Procedures in Plastic Surgery 137
otherwise acceptable health and deemed The flap choice is based on the size, tis-
fit for anesthesia. sue components, and reconstruction goals.
• Patients should quit smoking preopera- Attention to the logistics of patient posi-
tively as the risk of complications is tion and the feasibility of a two-team
similar to that of nonsmokers if they approach.
stop smoking 4 weeks before surgery.
• Obesity increases the risks of hemor-
rhage and hematomas. Consider recipient vessels in deciding the
• Alcohol withdrawal is also linked to flap length and caliber of the flap pedicle.
failure and nonflap-related complica-
tions. Patients at high risk for alcohol
withdrawal syndrome should be identi- 10.7 Current and Future
fied and treated prophylactically. Perspectives
• Diabetes mellitus is not an independent
risk factor for flap failure, but almost Several aspects of microsurgery might be
twofold the risk of perioperative impacted by technology in the next future. First
complications. of all, the robot-assisted surgery represents the
• Liver cirrhosis is a risk factor for periop- most up-to-date technological innovation in sur-
erative complications, but the disease gery. The Da Vinci Surgical System (Intuitive
severity based on Child’s scoring sys- Surgical Inc.™, Sunnyvale, USA) is the most
tem did not have an impact on commonly used. The platform can provide high
complications. definition, digital magnification, wide range of
motion, fine instrument handling with decreased
tremor and fatigue, and improved surgical pro-
ductivity. In reconstructive microsurgery, the
Pearls and Pitfalls application of robots is still preliminary. Mostly
Recipients and donor site evaluation was introduced in head and neck and breast
Radiotherapy impairs quality of local reconstruction. Transoral robotic surgeries have
tissues and vessels and predispose to eliminated lip- and mandible-splitting approaches
complications. and allowed the ablation of tumors that have until
Place the site the anastomosis outside recently been primarily treated with chemo-
the area of irradiation. radiotherapy, such as oropharyngeal cancer.
Infected or traumatic wounds should be Therefore, a robot-assisted insetting of the flap
adequately debrided. and microanastomosis was described and demon-
Reconstructive surgery postponed until strated to have similar outcomes compared to the
adequate control of the wound is achieved. standard approach but with less morbidity [29].
Preoperative angiography is recom- In breast reconstruction finds indications for spe-
mended in patients with abnormal distal cific free flaps harvest, which benefit from a min-
pulses. imally invasive approach. Few examples are the
Routine angiography is unjustified. latissimus dorsi flap [30] and the deep inferior
The design of the flap is centered on epigastric artery perforator flap [31].
perforators that are mapped by a hand-held However, since the Da Vinci Surgical System
Doppler. was not explicitly created for microsurgery, a few
Choice of flap limitations might be encountered, in particular in
There is no flap ideal for all terms of haptic feedback, which is crucial during
circumstances. microanastomosis and ergonomics. The latest
version of it, called the Single Port, may over-
138 F. Marchi and F.-C. Wei
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1998;82:346–50. ation of feasibility and morbidity of different surgical
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https://doi.org/10.1001/jamaophthalmol.2014.2316.
An Algorithm for Approaching
Soft Tissue Coverage
11
in the Twenty-First Century
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 141
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_11
142 L. P. Jiga and Z. Jandali
Our knowledge on using vascularised skin, anastomose vessels in the submillimetric calibre
bone or composite constructs to reconstruct tis- range are a prerequisite to warrant success.
sue defects all over the body has evolved based In an effort to further minimise the donor site
on pioneering vascular anatomy studies of morbidity and the overall burden of a free flap
Cormack, Lamberty, Taylor, Palmer and others surgery, several authors went further and using
[1, 2]. In 1989, Koshima et al., through their pub- performant ultrasound and CT angiography have
lication on the free epigastric skin flap (later to defined new anatomical layers for harvesting per-
become the deep inferior epigastric perforator forator flaps. The “supra-thin” flaps, although
[DIEP] flap), has ignited a new era of perforator pioneered by Kimata et al. and Kimura et al. in
flaps [3]. This concept was taken further and 1989 as “flap thinning after harvesting,” have
developed to a global phenomenon, several of known a new appraisal through the work of Hong
such perforator flaps being standardised to et al., which published in 2014 on harvesting
become workhorses for microsurgical recon- “supra-thin” flaps through the “superficial fascial
struction. The DIEP flap GAP flaps,, ALT flap plane” [10, 11]. This dissection in between the
and MSAP flap are some of the most relevant two fat layers at the groin, buttock or thigh level
contributions acting as instrumental evidence for yields very thin and pliable flaps, a technique best
the successful implementation and clinical use of suited for obese patients where possible skin flap
this concept [4–7]. The publishing of the perfora- donor areas are a major problem (Fig. 11.1).
some concept by St. Cyr et al. in 2009 was to add Lately, Visconti et al. communicate the use of
another important piece of evidence to the perfo- ultrasound to harvest and successfully revascula-
rator evidence and simultaneously open the doors rise “pure subdermal” flaps [12].
to the idea of “freestyle” harvesting of perforator In light of all these accumulating discoveries
flaps [8]. As such, the possible donor sites for and because of its obvious advantages, the perfo-
harvesting such flaps were expanded more or less rator flap has become the preferred choice for
to the entire human body, thereby giving way to a soft tissue reconstruction on a global level.
potpourri of new possible flap constructs. Nevertheless, while important discoveries for
With in-depth knowledge of vascular anat- the sake of science and advancement of our field
omy, rapidly accumulating evidence on indica- of knowledge, several of these techniques require
tion and clinical use of perforator flaps and unique skills (e.g. supramicrosurgery), which
unprecedented development of magnification and can only be mastered by a distinct rather small
microsurgical instruments, the stage was set for group of exceptionally gifted experts around the
the next ground-breaking discovery. The world. Furthermore, through the globalisation of
“perforator-to-perforator” concept pioneered and the perforator flap concepts, the “classical”
published by Hong et al. in 2013 provided con- established approaches to soft tissue reconstruc-
clusive evidence on the possibility of using perfo- tion seem to be coming of age, whereas perfora-
rator instead of main axial vessels at the recipient tor flaps gradually move to replace these as main
site to revascularise flaps in the lower extremity. indications for several types of tissue defects.
This technique is particularly relevant when While this being a direct and overall beneficial
approaching ischemic soft tissue loss in patients result of evolution, in certain instances using
with peripheral arterial disease and diabetes. perforator versus muscle flaps remains at least
Here, axial vessels are many times unusable for a an open discussion for the future. In order to
safe anastomosis, whereas perforator vessels keep this discussion field open and constructive,
(e.g. arteries), besides being enlarged due to the offering the new generations of plastic recon-
collateralisation process, are usually unaffected structive surgeons the means to master the clas-
by atherosclerosis, thereby offering the ideal sical approaches and flap types, before entering
recipient vessels in these challenging cases [9]. the realm of perforators and supra- or supermi-
However, supramicrosurgical skills successfully crosurgery, becomes mandatory and presumably
11 An Algorithm for Approaching Soft Tissue Coverage in the Twenty-First Century 143
a b
c d
Fig. 11.1 Supra-thin ALT flap for thumb reconstruction. arthrodesis (a), a free supra-thin ALT flap harvested
A 52-year-old patient with failed thumb replantation after between the superficial and deep fat layer (b, c) using low-
Level III amputation, which refused a toe-to-hand trans- intensity monopolar Colorado needle dissection was used
fer. After debridement of all soft tissues and IP joint to resurface the thumb (d, e)
144 L. P. Jiga and Z. Jandali
b c
Fig. 11.2 Soft tissue defect with calcaneal osteomyelitis a free ALT flap. Definitive bone reconstruction with an
after fracture and failed ORIF (a). Debridement of scared autologous graft was performed in a second step, 2 months
tissue and infected bone (b) followed by first-stage antibi- after soft tissue coverage. (c) Healed wound after soft tissue
otic bone replacement and soft tissue reconstruction using coverage with a free ALT flap and bone reconstruction
146 L. P. Jiga and Z. Jandali
a b c
d e
Fig. 11.3 Diabetic patient presenting with massive fore- infection control (b), a chain-linked medial sural artery
foot infection and septic shock as a complication of a perforator flap was used (c) simultaneously filling in the
long-lasting mal perforans with chronic osteitis of the forefoot defect and reconstructing the missing skin unit
fourth metatarsal bone (a). After radical debridement and (d, e)
tolerate transient but continuous reduction reanimate the normal gait followed by soft
of tissue perfusion while providing protec- tissue coverage might represent not only an
tive sensation. Another important issue to optimal therapeutic plan but an active mea-
consider when choosing the right flap is sure to prevent wound recurrence.
maintaining a low shear stress across the There are several muscle flaps that have
tissue planes. proved their clinical efficacy when dealing
In their meta-analysis published in 2015 with weight-bearing defects (e.g. last dorsi,
on the actual body of evidence regarding serratus anterior, gracilis); however, before
muscle vs. fasciocutaneous flaps for recon- harvesting a muscle, one always needs to
struction of the weight-bearing foot, Fox evaluate the possible functional deficit left
et al. conclude that both solutions are behind at the donor site. Moreover, muscle
equally effective for covering such defects flaps are known for their tendency to
while underlining the advantages of each remain bulky even years after surgery.
type of flap [15]. Thus, the reconstruction plan should defi-
While the medial plantar flap (either as nitely take into consideration the immedi-
pedicled or free flap) is the only flap able to ate and long-term effects such a flap will
fulfil a “like with like” reconstruction by have on the foot silhouette and function.
reconstituting the thick glabrous skin of the One smart but less used muscle flap,
foot sole, its limited dimensions make this which can be an optimal solution for cover-
flap usable only in small to moderate ing the weight-bearing foot, is the vastus
defects (Fig. 11.4). Thus, when dealing lateralis muscle. Described first by D’Arpa
with bigger defects, either fasciocutaneous et al. in 2015, the compartmental approach
or muscle flaps will need attention as the for harvesting the proximal superficial unit
primary reconstructive option. of this muscle provides a thin muscle flap,
Contemplating its structural anatomy, as which can also be reinnervated as a func-
compared with fasciocutaneous flaps, the tional transfer while inducing low to no
muscle flap covered with a split-thickness donor site morbidity [16].
skin graft would be the better option to As a clinical rule of thumb guidance
withstand weight-bearing and avoid principle, as patients get heavier and the
increased stress. Furthermore, looking at a defects get wider, the more probable one
normal gait analysis, the majority of will need a muscle flap covered with skin
weight-bearing during walking is distrib- graft and vice versa (the lighter the patient
uted on the tuberculum of the calcaneus and smaller the defect, the more probable a
(hindfoot) and the head of the five metatar- fasciocutaneous flap will do the job). As an
sals (forefoot). As such, when dealing with exception to this rule, in young patients
defects in these areas, a muscle flap could with posttraumatic significant loss of their
serve better the aims of reconstruction. weight-bearing foot, a thin muscle flap will
However, especially in diabetic patients always offer a better cushioning and func-
with neuropathic induced deformities (e.g. tional outcome (Figs. 11.5, 11.6, and 11.7).
Charcot), these pressure points have an Finally, one will always need to look
anomalous much wider distribution and into his own “toolbox” and offer only
need special consideration when evaluating reconstructive procedures one is familiar
such defects. One should not forget that with, as nothing is more dangerous to go
soft tissues are only “wrapping” as the into surgery planning to do something one
outer layer of the complex skeleton of the has never done before and not have at least
foot, and in these patients, preliminary one or two other options as “life boats,”
reconstruction of the bone structures to which will “save the day” if needed.
148 L. P. Jiga and Z. Jandali
a b c
Fig. 11.4 Chronic calcaneal ulcer in a diabetic patient and optimal pedicled flap for like-with-like reconstruction
(a). In such cases, in the presence of a patent tibial poste- of the defect (d)
rior artery, the medial plantar flap (b, c) can provide a fast
a b
Fig. 11.5 Soft tissue defect with the exposed bone after without fearing functional impairment (white arrow—
debridement of an infected pressure sore in a massively preserved motor branch to the deep compartment of the
overweight diabetic patient (a). The distal superficial vastus lateralis muscle) (b). Final result 1 year after sur-
compartment of the vastus lateralis muscle (dotted line) gery with adequate weight-bearing (c)
can be safely harvested (two white arrows—flap pedicle)
a b
Fig. 11.6 Unstable scar after amputation of the first toe due to frostbite (a). Radical debridement with bone length
preservation and direct soft tissue coverage using a free ALT flap with a satisfying results 1 year postoperatively (b)
a b c
d e f
Fig. 11.7 Young patient with complete bilateral forefoot tion of the soft tissue envelope using free vastus lateralis
necrosis after prolonged ECMO (extracorporeal mem- free flap (c, d, e) enabled optimal rehabilitation with full
brane oxygenation) support for septic shock (a—left foot ambulation using custom-made orthopaedic shoes
is shown). Atypical amputation with preservation of the 2 months postoperatively (f—final aspect of the recon-
hindfoot and tibiotalar joint (b) followed by reconstruc- structed area)
11 An Algorithm for Approaching Soft Tissue Coverage in the Twenty-First Century 151
Knowing the territories of each perforasome and eventually explore the ones that were found
in the presence of good perforators and careful to be relevant by the preoperative mapping. A
evaluation of the defect size as well as its poten- “good” perforator pedicle is defined by its
tial mirroring counterpart on the donor site are active pulsations, the presence of at least two
instrumental steps towards their successful har- healthy tributary veins, its calibre (e.g. the big-
vesting and use for defect coverage in the lower ger, the better) and optimal localisation accord-
extremity. ing to the defect borders (Fig. 11.8). Proper
In the authors’ experience, when dealing with measurement of the flap skin island in relation
defects requiring soft tissue reconstruction in the to the point the perforator pierces the fascia
lower leg, while preoperative perforator mapping towards the skin, wound size and potential
(Sono- or US Doppler) should always be per- defect of the donor site must all be evaluated
formed, it is presumably wiser not to consider a intraoperatively if a pedicled perforator flap is
local perforator flap as the first choice in the to be chosen for defect coverage (Fig. 11.9).
reconstructive plan. Should a proper perforator pedicle be found,
An appropriate free tissue transfer that is which is optimally positioned to allow optimal
proportional to your experience and defect flap harvesting whereas leaving a decent donor
characteristics should always be considered. site with no exposed tendon or bone, a local
While exposing the recipient vessels, be aware flap instead of the planned free tissue transfer
of all perforator pedicles underneath the fascia should be performed.
152 L. P. Jiga and Z. Jandali
c d
11 An Algorithm for Approaching Soft Tissue Coverage in the Twenty-First Century 153
cially (underneath the fascia) after which branch should be separately ligated (e.g.
both ends are anastomosed usually at the metal clips will not suffice as these can slip
level of the third segment of the popliteal away from a pulsating graft causing major
artery and vein. Even in advanced PAD, postoperative bleeding or even flap loss).
most often the distal popliteal or tibiopero- The choice of tunnelling should always be
neal trunk level remains open and free from decided intraoperatively. While in thin
severe wall calcifications or obstruction. patients, anatomical tunnelling under the
The flap can be finally anastomosed to the medial soleus muscle within the deep pos-
distal end of the loop either to the vein graft terior compartment of the shank is usually
or, if needed, for a better calibre match, on possible, adipose patients mostly require
a venous branch of the venous graft itself subfascial loop placement. Both ways, tun-
(Fig. 11.10). While proximally vascular nels should be carefully prepared using
anastomosis of the venous loop is facili- blunt long instruments (either dressing for-
tated by big calibre vessels, distally the flap ceps or special vascular graft tunnelling
vessels can be safely anastomosed on pris- tools) inserted carefully and if possible
tine venous walls using a basic microsurgi- under direct view. During anatomical tun-
cal technique, thus lowering the chance of nelling, rupture of collateral veins of the
thrombosis or other anastomosis-related tibial posterior or peroneal artery can cause
complications. major bleeding. Thus, while easier to per-
If longer loops are needed (vascular form as the “perforator-to-perforator” prin-
access for the mid- or distal foot), two ciple, this technique can elicit a fair number
veins joined in continuity can be used, of complications if not applied in the right
yielding loops over 55-cm-long loops. The clinical context. As both techniques can
length of the loop should be calculated by offer a proper means of soft tissue coverage
measuring the distance from the proximal in the ischaemic lower extremity, vascular
vessels until 3–4 cm from the proximal workup in the context of type and exten-
margin of the defect and adding 4–5 cm to sion of the tissue defect becomes instru-
this length. In this way, one can avoid pos- mental for setting the correct indication for
sible length deficits or eliciting too much reconstruction. For massive infected
tension on the loop to reach the defect, both wounds with exposed bone in the absence
of which being deleterious to an optimal of adequate vascular support for the
functioning vein graft. Before loop con- affected limb, primary amputation should
struction, each vein must be thoroughly always be considered.
explored under loupe magnification, each
11 An Algorithm for Approaching Soft Tissue Coverage in the Twenty-First Century 155
c d
156 L. P. Jiga and Z. Jandali
third category present with defects, which achieve successful soft tissue reconstruc-
according to their localisation, dimensions tion optimally tailored to each particular
and aetiology will be amendable only defect, all over the body. However, the user
through free flaps regardless of possible will need to already have attained several
favourable local anatomy for a local flap local and free flap techniques as well as
procedure. have detailed knowledge of anatomy of the
The authors are confident that using this approached body area in order to effec-
“drive-through” algorithm for one can tively use this concept.
Fig. 11.11 The “drive-through” concept for approaching soft tissue reconstruction
158 L. P. Jiga and Z. Jandali
a b c
d e
Fig. 11.12 Patient with wound breakdown and exposed using a chimeric ALT flap (c) with a vastus lateralis mus-
vascular graft after explanation of an infected aortobifem- cular component (*) tunnelled under the sartorius muscle
oral dacron prosthesis (a). Vascular reconstruction through (arrows) to close the dead space around the exposed pros-
a left aortofemoral bypass completed with a cross-over thesis (d) and the skin flap used to reconstruct the missing
biological coated jump graft extension to the right com- skin envelope of the groin (e)
mon femoral artery (b). The defect was reconstructed
11 An Algorithm for Approaching Soft Tissue Coverage in the Twenty-First Century 159
a c d
Fig. 11.13 Soft tissue defect of the knee and shank with branch of the lateral circumflex femoral artery was found
exposed patellar tendon after heroin injection and massive and used as a retrograde pedicle for the ALT flap, which
infection (a). While harvesting a planned free ALT flap to was rotated in a propeller manner to completely close the
cover the defect, a strong distal segment of the descendent defect (b, c, d)
160 L. P. Jiga and Z. Jandali
a d
Fig. 11.14 Locally advanced erosive breast cancer with perforator) with SCIP (superficial circumflex iliac artery
involvement of the thoracic wall (a). Radical resection perforator) flap with in-flap anastomosis between the
with axillary clearance and preventive lymphovenous SCIP pedicle and the cranial stump of the ipsilateral deep
anastomosis (LymPHA approach nach Campisi [18]) (b). epigastric pedicle (c). Result immediately postoperative
Compound double-DIEP (deep inferior epigastric artery (d) and 1 year after reconstruction (e)
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Part ll
Plastic Surgery Approaches to
Malformation
Craniofacial Malformations
12
Mario Zama and Maria Ida Rizzo
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 167
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_12
168 M. Zama and M. I. Rizzo
12.2 Craniofacial Clefts equator and passes laterally from the lateral can-
thus [5–8] (Fig. 12.2). Because the cranial and
Craniofacial clefts are among the most disfigur- facial clefts tend to follow the same axis, Tessier
ing of all facial anomalies, occur in different incorporated this concept as the keystone of his
degrees of severity, and include distortions of classification and with the analysis of the patient
cranium and face with deficiencies or excesses of [5–8].
tissues that cleave anatomic planes. Unilateral The no.0–14 cleft of Tessier is a median cra-
forms are the most common [3]. The majority niofacial dysraphia. It is comparable to the fron-
occur sporadically. However, inheritance plays a tonasal dysplasia of Sedano [10], also referred to
role in some rare craniofacial clefts (e.g., a domi- as centrofacial microsomia. The cleft involves
nant gene defect, TCOF1, causes Treacher– the frontal bone, the ethmoid region with a dupli-
Collins syndrome) [9]. cation of the crista galli, the nose with a duplica-
In the Tessier classification system, a number tion of the septum and columella, the maxilla,
is assigned to the site of each cleft, based on its and lip. A diastema separates the central incisors,
relationship to the sagittal midline. The facial and a cleft palate can be present.
clefts are distributed around the orbit, the eyelids, The no.0 cleft usually results in hypertelorism,
the maxilla, and/or the lips [5–8]. Clefts of the whereas, if agenesis or hypoplasia is the predom-
soft tissues and clefts of the craniofacial skeleton inant malformation, a partial or total absence of
may not always exactly coincide. A horizontal the philtrum and the premaxilla can occur. The
line can be drawn through the canthi as an equa- nose can be small, without columella, with nos-
tor to divide the cranial and facial portions of the trils that are laterally displaced, resulting often in
cleft. Clefts develop according to constant axes, a bifid nose. At the other extreme, a proboscis or
which are divided into 15 regions numbered 0–14 arhinencephaly can be seen with the resultant
around the orbit. The clefts 0–7 (facial cleft) are orbital hypotelorism or cyclopia.
found caudal to the orbital equator, and the 9–14 Prolongation of the no.0 cleft onto the mandi-
(cranial cleft) are found cephalad to the orbital ble, or no.30 cleft of Tessier, could be represented
equator. The number 8 cleft coincides with the in its minor form as a notch in the lower lip and
13 12 10
12 4
11 9
1
2 7
3 6
4
5 7
20
30
12 Craniofacial Malformations 171
become progressively more severe by involving cavity, maxillary sinus, and oral cavity are all
the mandible, tongue, chin, neck, hyoid bone, confluent. The Tessier no.10 cleft is the superior
and even the sternum. The tongue is frequently extension of this cleft.
bifid and bound to the mandible by a band of tis- The Tessier no.5 cleft is the rarest of the
sue. The cleft of the alveolus is located in the oblique facial clefts. The cleft of the lip is found
midline between the central incisors. medial to the angle of the mouth but not at the
The Tessier no.1 cleft is a paramedian cranio- commissure. It courses upward across the lateral
facial cleft. The cleft passes through the soft tis- cheek to and between the eyelid. The vertical dis-
sues from the Cupid’s bow region to the dome of tance between the mouth and lower eyelid is
the alar cartilage. If the no.1 cleft extends superi- decreased, resulting in a pulling of the upper lid
orly onto the frontal bone, it is referred to as the and lower eyelid toward each other.
no.13 cleft. The olfactory groove of the cribri- Microphthalmia is infrequently present. The
form plate becomes widened, resulting in hyper- bony malformation parallels the path of the cleft.
telorism. Inferiorly, the no.1 cleft continues The alveolar portion of the cleft is found in the
through the alveolar bone. premolar region. Passing lateral to the infraor-
The Tessier no.2 cleft is a paranasal location bital foramen, the cleft enters the orbital floor
that crosses the soft tissue of the nose, the alar, with prolapse of the orbital contents.
and the lip. Distortion of the eyebrow occurs if The Tessier no.6 cleft is characteristically rec-
the cleft continues into the frontal region as a ognized as the incomplete form of the Treacher–
no.12 cleft. The nasolacrimal system is not dis- Collins–Franceschetti syndrome. The external
turbed as in the no.3 cleft. Enlargement of the ears can be almost normal, but a hearing deficit is
ethmoidal labyrinth results in hypertelorism. often present. The antimongoloid slant of the pal-
Usually, the glabella is flattened, and the frontal pebral fissures is milder. The bony malformations
sinus is enlarged. of this cleft set it apart from the complete form of
The Tessier no.3 cleft is a medial orbitomaxil- the syndrome: the malar bone is present but
lary cleft. Through the bony skeleton, it traverses hypoplastic with an intact zygomatic arch. The
obliquely across the lacrimal groove. The frontal cleft runs between the hypoplastic malar bone
process of the maxilla is often absent. Through and the maxilla in the region of the zygomatico-
the soft tissue, the cleft passes across the lower maxillary suture.
eyelid, the alar base, the nasolabial fold, and the The Tessier no.7 cleft is the most common. It
lip and alveolar ridge. The mildest form of this groups several anomalies (necrotic facial dyspla-
cleft is represented by a coloboma of the nasal sia, hemifacial microsomia and microtia, oto-
ala. The vertical distance between the alar base mandibular dysostosis, unilateral facial agenesis,
and the medial canthus is disturbed, and the naso- auriculobranchiogenic dysplasia, hemignathia
lacrimal duct is obliterated. The severest form of and microtia syndrome, lateral/transverse facial
ocular involvement is microphthalmia. The clefts, and oro-mandibular-auricular syndrome).
Tessier no.11 cleft represents the superior exten- Goldenhar’s syndrome is also comparable in
sion of this cleft. many of its features but, in addition, involves epi-
The Tessier no.4 cleft is a median orbitomaxil- bulbar cysts and vertebral anomalies. The clinical
lary cleft. Through the soft tissues, it traverses expression of the no.7 cleft varies from a slight
almost vertically the lip, eyelids, and eyebrow facial asymmetry with minimal auricular malfor-
passing laterally to the alar base. The nasolacri- mations to severe ear malformations. Hypoplasia
mal canal and lacrimal sac remain intact. In the of the maxilla, temporal bone, soft palate, and
severest forms, there is anophthalmia. The cleft tongue has been seen. The parotid gland can be
on the maxilla passes medial to the infraorbital absent. The fifth and seventh nerves can be
foramen and produces a bony defect in the infe- involved, along with their innervated muscula-
rior orbital rim and floor, with consequently ture, represented by weakness of masticatory and
orbital dystopia. In the complete form, the orbital facial expression muscles. As a result of the
172 M. Zama and M. I. Rizzo
hypoplastic maxilla and the reduced height of the flattening results in telecanthus. The ethmoidal
mandibular ramus, there is a defect of the occlu- labyrinth is increased resulting in hypertelorism.
sal plane. In the complete form, the mandibular The cleft in the soft tissues extends from the root
condyle and ramus can be missing. of the eyebrows and into the frontal hairline. The
The Tessier no.8 cleft is very rare. The soft tis- cranial equivalent of the no.12 cleft is facial cleft
sue cleft begins at the lateral canthus and extends no.2.
toward the temporal region. The lateral coloboma The Tessier no.13 cleft corresponds to the cra-
can be occupied by a dermatocele. nial extension of the no.1 facial cleft. The distinc-
Tessier has noted that there is a unique bilat- tive features are the widening of the olfactory
eral combination of clefts no.6–7-8, known as grooves and cribriform plate, resulting in hyper-
Treacher–Collins syndrome, Franceschetti– telorism; an omega-shaped disruption of the hair-
Zwahlen–Klein syndrome, or mandibulofacial line; and lateral displacement of the eyelid and
dysostosis. The hallmark of this syndrome is the eyebrow.
absent malar bone. Soft tissue malformations The Tessier no.14 cleft, as opposed to the no.0
result in coloboma of the lower eyelid with par- cleft, is always associated with hypertelorism.
tial deficiency of the eyelashes; the eyelid colo- The orbits tend to remain in the fetal position, the
boma and antimongoloid slant of the palpebral cranium is bifidum or displaced by a large medial
fissure; absence of the lateral orbital rim with frontal encephalocele, the crista galli is widened
associated lateral canthal dystopia; absence of or duplicated, and the ethmoid bone prolapses
the zygomatic arch, fusion, and hypoplasia of caudally.
masseter and temporalis muscles, microtia with This completes the axial dysplasia of the cra-
conductive hearing loss; and mandibular defi- niofacial clefts proposed by Tessier [5–8], based
ciency with retrognathia and open bite. on bone and soft tissue landmarks, which seems
The Tessier no.9 cleft is a superolateral orbital to have a direct relationship with neuromeric
cleft that continues into the frontotemporal cra- theory.
nium, traversing laterally the upper eyelid. This
cranial cleft corresponds to facial cleft no.5.
Key Point
The Tessier no.10 cleft is a central superior
Craniofacial clefts are among the most dis-
orbital cleft that extends across the roof of the
figuring of all craniofacial anomalies.
orbit and the frontal bone. The soft tissue defor-
Tessier’s classification is the most
mity is characterized by the central coloboma of
accepted classification system. It divided
the upper eyelid. The eyelid and eyebrow are
the clefts into 15 regions numbered 0–14
divided into two portions. Its severest form
around the orbit, in relationship to the sag-
occurs as a lack of eyelids. The no.10 cleft
ittal midline. Clefts 0–7 (facial cleft) are
appears to be the more superior cranial equiva-
caudal to the orbital equator (the horizontal
lent of facial cleft no.4. Both clefts can have a
line drawn through the canthi); 9–14 (cra-
coloboma of the iris.
nial cleft) are cephalad to the orbital equa-
The Tessier no.11 cleft is a superomedial
tor; and the Tessier no.8 cleft coincides
orbital cleft. The coloboma of the upper eyelid
with the equator and passes laterally from
can extend to the eyebrow and into the frontal
the lateral canthus.
hairline. It is the cranial equivalent of facial cleft
no.3. It can pass lateral to the ethmoid bone with
a cleft in the eyebrow and orbital rim, or it can
pass through the ethmoid labyrinth, resulting in 12.3 Cleft Lip and Palate
orbital hypertelorism.
The Tessier no.12 cleft is located medial to Cleft lip and palate is the most common congeni-
the medial canthus, passing through the frontal tal facial anomaly. The incidence ranges from 0.6
process of the maxilla and the nasal bone. This to 2.13 per 1000 births [4]. Cleft lip—with or
12 Craniofacial Malformations 173
without cleft palate—is seen more commonly in the primary palate anterior to the incisive fora-
males, while isolated cleft palate has a higher men are numbered 1–5 and 11–15. Clefts of
incidence in females. Asians have the highest the secondary palate posterior to the incisive
incidence, while Africans have been found to foramen are numbered 6–9 and 16–19 [13].
have the lowest incidence. It may be associated
with syndromes but more frequently occur spo- Berkowitz has suggested that the numerous
radically. Cleft lip may be unilateral (right or left morphologic varieties of cleft lip and palate may
sided) or bilateral, complete or incomplete, with segregate into four categories: a) clefts involving
or without cleft palate. The most used classifica- the lip and alveolus; b) clefts involving the pri-
tion systems are to follow: mary palate (lip) and secondary palate; c) clefts
involving only the secondary palate; and d) clefts
–– The Kernahan striped Y is the most used dia- involving congenital insufficiency of the palate
grammatic classification system that describes (velopharyngeal dysfunction, submucous cleft
cleft anatomy and severity [11]. By conven- palate) [14].
tion, the primary palate consists of premaxilla, Veau described a classification divided into
anterior septum, and soft tissues of the central four groups: (1) cleft of the soft palate; (2) cleft
part of the lip (philtrum). The secondary pal- of the hard and soft palates up the incisive fora-
ate is separated from the primary palate by the men; (3) complete unilateral cleft; and (4) com-
incisive foramen and consists of the remaining plete bilateral cleft [15] (Fig. 12.4).
hard palate, the soft palate, and the uvula [12]. The American Association for Cleft Palate
The limitation of the Kernahan Y classifica- Rehabilitation divides all clefts into two major
tion is that clefts of the secondary palate can- categories: prepalate (lip and alveolar process to
not be classified into right or left sides. So, the incisive foramen) and palate (soft palate, hard
Y classification was modified into a better palate to incisive foramen) [16].
numeric system (Fig. 12.3), in which clefts of Clinically, cleft lip presents several osseous
and soft tissue dysmorphology: the premaxilla is
R L projecting (and rotated in unilateral form); the
1 Nosrtril floor 11 lateral maxillary elements are retropositioned;
Lip the orbicularis oris muscle inserts into the alar
2 12 wing; the philtrum is short; the nasal alar carti-
Alveolous
lage on the cleft side is displaced and flattened;
3 13 the tip of the nose is deviated toward the noncleft
4 14 side; the septum is dislocated out of the vomerine
5 15 groove; the alar base is rotated; the columella is
Incisive foramen distorted; and vestibular lining is deficient.
6 16 Cleft lip and palate may show different sever-
ity ranging from a submucous cleft palate, where
Hard palate
the mucosa is intact, but the muscles fail to fuse
7 17
on the midline, to a complete cleft of the soft pal-
ate, hard palate, alveolus, and lip.
8 18 However, approaching this anomaly, it is man-
Soft palate datory to know the aberrant anatomy in alveolar
9 19
and palatal cleft. The alveolar process is the ridge
of the bone on the maxilla that provides support
for the teeth. This bone develops with tooth erup-
10 Submucous tion and resorbs when teeth are lost. Palate clefts
form along the epithelial fusion plane between
Fig. 12.3 Kernahan’s striped Y classification modified the premaxilla and the lateral segments of the
174 M. Zama and M. I. Rizzo
a b c d
Fig. 12.4 (a) Cleft soft palate; (b) cleft and hard palate to the incisive foramen; (c) complete unilateral palate, alveolus
and lip; (d) complete bilateral palate, alveolus and lip
Key Point
Cleft lip and palate is the most common
congenital facial anomaly. The range of
severity varies from submucous cleft palate
Fig. 12.5 Muscle displacement in the cleft soft palate to complete cleft of soft and hard palate
along with cleft of alveolus and lip.
maxilla: this is the reason for the frequent absence
Cleft lip can be diagnosed in the prenatal
of the lateral incisor on the cleft side [17].
period by ultrasound, while the diagnosis of
In hard palate clefts, the vomer can be seen in
cleft palate is usually made at birth.
the midline, inside the nasal cavity. In a unilateral
Submucosal cleft palate can have a late
cleft palate, the vomer remains attached to the
diagnosis.
noncleft side.
Several classification systems exist. The
When a cleft of the soft palate is present, the
most important are Kernahan striped Y,
muscles are displaced anterolaterally, along the
Berkowitz, and Veau.
cleft margins (Fig. 12.5), while the palate apo-
neurosis is displaced laterally [18].
Cleft lip can be diagnosed in the prenatal period
by ultrasound, while the diagnosis of the cleft pal- 12.4 Craniosynostosis
ate is usually made at birth. At diagnosis, it is
essential to send parents to a cleft center for coun- Craniosynostosis is a craniofacial deformity
seling about feeding and treatment plans. The cleft caused by the premature closure of one or more
team will teach parents about feeding techniques of the cranial sutures. It represents one of the
12 Craniofacial Malformations 175
major groups of congenital craniofacial malfor- trusion. The face also is distinctive due to
mations. Virchow, in 1851, was the first to coin excessive narrowing of the interorbital space:
the word craniostenosis. The term craniosynos- orbital hypotelorism, epicanthal folds, and low
tosis has been introduced recently to describe the nasal dorsum.
process of premature fusion, with craniostenosis Complete or bilateral coronal synostosis is
being the result. known as brachicephaly because of the short
There are several different types of craniosyn- head shape. The cranium has a decreased antero-
ostosis. The simple form refers to the involve- posterior diameter and an increased temporopari-
ment of one suture being prematurely fused, etal width. The facies are characteristic: the
whereas the complex form involves synostosis of forehead is usually high with cephalad promi-
two or more sutures [20]. All of them have a typi- nence that protrudes beyond the brow recession
cal phenotypic expression (Table 12.1). and is excessively broad. There is superior exor-
Craniosynostosis with single-suture synosto- bitism due to the shortness of the anterior cranial
sis includes metopic, coronal, sagittal, and lamb- base and orbits. Bilateral coronal synostosis can
doid synostosis. These deformities generally be nonsyndromic, although it is more commonly
appear to be isolated and therefore are named associated with syndromic craniosynostoses. It is
nonsyndromic. The isolated craniosynostosis more common in females.
form is present in patients who usually have no Lambdoid synostosis is the less common non-
other abnormalities. The severity of the resultant syndromic craniosynostosis. Generally, it is uni-
deformity is directly proportional to the area of lateral and is known as posterior plagiocephaly. It
suture involved. The range of facial deformation is more common in the male. The cranium is
can be minimal, as in the scaphocephaly malfor- asymmetric and the primary dysmorphism is in
mation with premature closure of the sagittal the occiput. The mastoid projects more caudally.
suture, to greater, as noted in trigonocephaly with Frontal bone, eyebrows, and orbits have minor
premature closure of the metopic suture. asymmetry with nasal and chin deviation.
Sagittal synostosis is the most frequent non- Posterior plagiocephaly must be differentiated
syndromic craniosynostosis. It is known as from deformational plagiocephaly that is a posi-
scaphocephaly. It is more common in the male. tional skull deformity associated with nonsynos-
Fusion of the sagittal suture impairs expansion of totic causes, most commonly with sleep position.
skull width, which is compensated by excessive
skull length. This increase of the cranial antero-
posterior diameter includes an expansion of the Key Point
anterior and posterior fossae. Craniosynostosis results from a premature
Unilateral coronal synostosis is the second closure of one or more of the cranial sutures
most frequent nonsyndromic craniosynostosis. It and has a typical phenotypic expression.
is known as anterior plagiocephaly. It is more Craniosynostosis with single-suture
common in females and has a notable impact on synostosis includes metopic, coronal, sag-
facial growth. The frontal region is more ittal, and lambdoid synostosis. These defor-
deformed than the occiput, with recession of the mities generally are isolated and so are
forehead ipsilateral to the synostosis and protru- nonsyndromic; instead, syndromic cranio-
sion contralaterally. The major facial deformity synostosis is characterized by multiple
consists of right–left asymmetries and deviation malformations. Nonsyndromic craniosyn-
of the midline (nose, lips, and chin). ostosis is known as scaphocephaly, plagio-
Metopic synostosis is the third most frequent cephaly, trigonocephaly, and
nonsyndromic craniosynostosis and is known as brachycephaly, in order of incidence.
trigonocephaly. It is more common in the male. Deformational plagiocephaly is a non-
Patients are considered the most at risk for cogni- synostotic positional skull deformation
tive or behavioral impairment. The cranium has a associated most commonly with sleep
triangular shape with a midfrontal keel, bifronto- position.
temporal narrowing, and parietal-occipital pro-
176 M. Zama and M. I. Rizzo
ear deformity, mandibular hypoplasia, the mandible curves upward to join the vertically
involvement of the marginal mandibular reduced ramus. The chin is deviated to the
branch of the VII cranial nerve, and soft tissue affected side. Condyle malformation varies from
hypoplasia. minimal hypoplasia to complete absence.
–– Diagnosis of Goldenhar syndrome includes Condylar anomalies are constants and, conse-
epibulbar dermoid and vertebral anomalies in quently, pathognomonic of this syndrome (see
association with the typical features of the cra- Pruzansky classification of severity). The neuro-
niofacial microsomia. Common in Goldenhar muscular components are also distorted or defi-
is also macrostomia, which may be the appear- cient, and the occlusal plane is inclined.
ance of a lateral cleft of the lip. Microphthalmia, coloboma, orbital dystopia,
cranial base anomalies, cleft lip and palate,
The most conspicuous deformity in CMF is velum paresis, and velopharyngeal insufficiency
auricular malformations, mandibular hypoplasia, have been reported, as well as dental hypopla-
and craniofacial anomalies. sia, plagiocephaly, parotid gland hypoplasia,
According to Marx, auricular malformations cranial nerve defects, and sensorineural hearing
include microtia: grade I, distinctly smaller mal- loss [27]. It can be bilateral in 5% to 30% of
formed ear with most of the characteristic com- cases.
ponents; grade II, vertical remnant of skin and
cartilage, with atresia of the external meatus;
grade III, the external ear is absent except for a 12.5.4 Frontonasal Malformations
small remnant, such as a misplaced deformed
lobule. Other principal auricular anomalies are Frontonasal malformation (Fig. 12.9) can be iso-
preauricular tags, conductive hearing loss, and lated or syndromic. It is also known as median
middle ear (ossicle) defects. cleft facial syndrome or median face syndrome,
Mandibular hypoplasia is characterized by a and it is comparable with Tessier 0–14 cleft. First
ramus hypoplastic or virtually absent, the body of named frontonasal dysplasia, successively fron-
12.6 Microtia
Key Point Microtia affects the external ears and occurs once
Craniofacial malformations may be syn- in every 1200–6000 births (the prevalence of
dromic or nonsyndromic, respectively, if microtia varies depending on the population
they are associated with other malforma- studied; the higher incidence is in the Navajo
tions or isolated defects (e.g., cleft lip and population) [32, 33]. The majority of the patients
palate, craniosynostosis, microtia). also have conductive hearing loss.
Syndromic craniofacial malformations External ear is composed of several important
include the following: landmarks that begin to develop during the fifth
week of gestation from the first (tragus, helical
• Syndromic craniosynostosis, such as root, helix) and second (antihelix, antitragus, lob-
Crouzon disease, Apert syndrome or ule) pharyngeal arches. These malformations
acrocephalosyndactyly, Pfeiffer syn- range from minor irregularities in the contour and
drome, Saethre–Chotzen syndrome, size to a complete absence of the ear (known also
Jackson–Weiss syndrome, Carpenter as anotia). Many classification systems have been
syndrome, Kleeblattschadel deformity, proposed. The most popular are the four Hunter
Muenke syndrome, and Opitz degrees (presence of all components but smaller
syndrome. size, presence of some recognized components,
• Facial syndromes, such as Treacher– presence of some not recognized components,
Collins or Franceschetti syndrome, anotia) and the five Nagata types (lobule, small
concha, concha, anotia, low hairline). The most
184 M. Zama and M. I. Rizzo
Key Point
Microtia affects the external ear and has a
phenotypic spectrum varying from hypo-
plasia to partial presence of recognized/not
recognized ear components, up to anotia.
It is isolated or syndromic. The most
common syndrome associated is craniofa-
cial microsomia (including oculoauriculo-
vertebral spectrum, Goldenhar syndrome,
hemifacial microsomia).
12.7 Micrognathia
may be necessary depending upon jaw growth transcranial means through the anterior cranial
and development. base. Tessier developed models for preoperative
planning and established surgical techniques that
permitted to treat many patients with varieties of
Key Point
congenital deformities. His teaching in Paris and
Micrognathia or mandibular hypoplasia
worldwide spread the news rapidly. As a result,
interfere with feeding and breathing.
the craniofacial surgeons on every continent
It is linked to several craniofacial anom-
established their own teams.
alies, such as cleft lip and palate, Pierre
Two fundamental aspects must be considered
Robin sequence, Stickler’s syndrome,
in craniofacial surgery: the surgical anatomy and
hemifacial microsomia, Treacher Collins
the fourth dimension (growth over time) since
Franceschetti syndrome, and others.
craniofacial growth is a dynamic process that
affects both form and function [38].
From a surgical anatomy point of view, the
12.8 Craniofacial Malformation craniofacial area consists of two structures: the
Surgery cranium and the face.
The cranium is composed of the vault and the
Craniofacial surgery is a teamwork that begins base.
at the prenatal diagnosis or immediately after The vault is formed by the frontal bone, single
birth and continues until the end of facial growth and median, the two parietals, the upper part of
(around 18 years of age). This means that cra- the occipital bone, and the two temporal fossae.
niofacial surgery is not confined to the operative In the cranium of the newborn, the skeletal parts
treatment but includes all the activities con- are separated from each other by the sutures
nected to the correct development of the skull (bands of connective tissue) and fontanelles (sites
and face. It takes place in specialized pediatric of suture junction between three or four bones).
centers with specific expertise in craniofacial The metopic suture (between the two frontal
malformations. bones) closes before birth and disappears around
As Paul Tessier, father of the discipline, stated the 15th month of life. The other sutures close
that craniofacial surgery consists in the transcra- slowly up to the 18th month (Fig. 12.11). They
nial approach to the orbits and maxilla, where are the following:
Anterior
fontanell
Coronal
suture Posterior fontanella
Sfenoidal Lambdoyd suture
fontanell
Mastoid
Anterior fossa
fontanella
Medial fossa
Posterior fossa
Mastoid fontanella
–– Coronal (between frontal and parietal bones). The centrofacial portion is a pyramid com-
–– Sagittal (between parietal bones). posed of the maxillo-ethmoidonasal complex.
–– Lambdoid (between parietal and occipital Deep inside, this centrofacial complex supports
bones). the velum and the palatopharyngeal muscle
–– Parietosquamous (between parietal and tem- slings [39].
poral bones). The orbits represent the upper third of the face
–– Sphenofrontal and sphenotemporal (between and include four walls:
cranium and face).
–– Roof (superior): orbital part of the frontal
The fontanelles are placed at the four corners bone, lesser wing of the sphenoid bone.
of the parietal bone and are named bregmatic, –– Medial: orbital plate of the ethmoid bone, lac-
lambdoid, pteric, and asteric (Fig. 12.11). rimal bone, frontal process of the maxilla,
The base is formed by the posterior, middle, greater wing of the sphenoid bone.
and anterior fossae. These reproduce the tribasi- –– Floor (inferior): orbital surface of the maxilla,
lar bone of Virchow (basiocciput, basisphenoid, zygomatic bone, palatine bone.
and presphenoid). Each fossa accommodates a –– Lateral: zygomatic bone, sphenoid bone.
different part of the brain.
The anterior fossa is of particular interest in The zygomatic bones continue inferolater-
craniofacial surgery. It is a territory with an ally and complete the upper two-thirds of the
unpaired midline area leading to the nasopharynx face.
and two paired lateral areas that are the orbital The lower third of the face is formed by the
roofs. The anterior fossa is supported by the body alveolodental sector and mandible. It comprises
of the sphenoid, articulating with the frontal bone the oral cavity.
and ethmoid bone. This fossa accommodates the The visible craniofacial surface is character-
anteroinferior portions of the frontal lobes of the ized by the hairy scalp in cranial portion and the
brain. The ethmoid bone in particular contains hair-less skin in the face with typical hairy zones
the main foramina of the anterior cranial fossa for (eyebrow, mustache, and beard). Facial skin is
transit of vessels and nerves (I cranial nerve). lined by the mimic muscles innervated by the
The middle cranial fossa consists of three facial nerve.
bones, the sphenoid and the two temporals. It con-
tains many nerves, vessels, and cranial structures
crucial to its function. The middle cranial fossa Pearls and Pitfalls
consists of a central portion, which contains the • Craniofacial surgery is a teamwork that
pituitary gland, and two lateral portions, which begins at the prenatal diagnosis or
accommodate the temporal lobes of the brain. immediately after birth and continues
The posterior cranial fossa is the most poste- until the end of facial growth (around
rior and deep of the three cranial fossae. It accom- 18 years old).
modates the brainstem and cerebellum. It is • It is not confined to the operative
composed of three bones: the occipital and the treatment.
two temporal bones. There are several bony land- • It takes place in specialized pediatric
marks and foramina present in the posterior cra- centers with specific expertise in cranio-
nial fossa for the passage of blood vessels or facial malformations.
nerves (Fig. 12.11). • A fundamental aspect to be evaluated in
The face has sutures that unite the bones of the this surgery is the fourth dimension
facial complex and the latter to the vault and cra- (growth over time).
nial base. It is formed by 14 bones.
12 Craniofacial Malformations 187
Fig. 12.12 Pre- and postoperative of Tennison–Randall technique; and pre- and postoperative of Millard technique
the commissures; the philtral column in cleft side A dissection of the alar cartilage of the cleft
and in noncleft side (in unilateral cleft lip); and side and alar transfixion sutures can complete the
the horizontal and vertical length. operation, and postoperative splinting of the nos-
Surgery was simple until the Tennison and tril with a silicone conformer can limit the effects
Randall method. Indeed, this was the start of a of wound contracture.
more sophisticated repair with actual preserva- In bilateral cleft lip, the additional problems
tion and positioning of the Cupid’s bow by using are the skin imbalance between prolabium and
a triangular flap technique. In 1955, Millard pre- columella, the premaxilla does not connect to
sented his rotation-advancement technique, pub- the lateral palatal shelves, the premaxilla is pro-
lished in 1957. Since then, Tennison–Randall and jected anteriorly, and there is the absence of
Millard repairs (Fig. 12.12) have been the most muscle under the prolabium. Several techniques
popular types of reconstructions, with many for bilateral cleft lip repair have been described.
modifications. Mostly, the Millard technique The Millard method adapted from bilateral cleft
spans a lifetime of change and innovation. In the lip repair can be applied. Interesting and wide-
50 years since the introduction of the rotation- spread is also the Mulliken approach [44]. Its
advancement, many further refinements have markings for the operation include the standard
been proposed, including those by Byrd, Cutting, anthropometric landmarks: subnasale, sub-
Mohler, Mulliken, Stal, and others [42]. Recently, alaris, labiale superius, crista philtri superioris,
Fisher devised the anatomical subunit approxi- crista philtri inferioris, and the vermilion/
mation technique, which is an evolution of geo- mucosal junction (red line). On the prolabium,
metric style repairs [43]. the philtral flap is designed. For the typical
The key points in unilateral myocheiloplasty infant, this flap should be 2 mm wide superi-
are the reconstruction of the Cupid’s bow, orbicu- orly, 4 mm wide inferiorly, and 6–7 mm in
laris muscle release and approximation, complete height, with sides drawn gently concave. Two
mucosal and vermilion closure, definition of the flanking flaps should be drawn 2–3 mm in width
alar groove, and the philtral column. In the on each side and deepithelialized. These flank-
Millard technique, there is the rotation of the ing flaps improve the vascular supply of the
noncleft side upper lip, the advancement of the philtral flap and may simulate the philtral ridge.
cleft side upper lip, and the versatile C flap that Below the filter flap, the orbicularis oris muscle
can be placed laterally (beneath the ala) or medi- from the lateral elements is joined in the
ally (rotating into the columella). midline.
Reconstruction of the orbicularis oris muscle Small C-flaps are drawn on each side of the
in lip repair is essential to achieve a good appear- prolabium and are then approximated to the alar
ance and function. base flaps.
12 Craniofacial Malformations 189
Mulliken completes the repair with bilateral The most important aspect of surgical anat-
alar rim incisions for placement of intercartilagi- omy is the emergency of the greater palatine neu-
nous and interdomal sutures. rovascular bundle from the greater palatine
In expert hands, both Millard and Mulliken foramen through the lateral posterior hard
techniques can give excellent results [45]. palate.
Unilateral complete cleft lip and palate is
characterized by direct communication between
the entire length of the nasal passage and oro-
Pearls and Pitfalls
pharynx. The nasal septum is deviated and buck-
–– Adequate rotation of the Cupid’s bow is
led toward the cleft side. The absence of a portion
one of the most important aspects in
of the inferior piriform aperture and the hypopla-
achieving a good esthetic result, and
sia of the lateral nasal bony platform at the maxil-
reconstruction of the orbicularis oris
lary wall contribute to the cleft nasal deformity;
muscle in lip repair is essential to
the nasal base is depressed, the ala collapses, and
achieve a good appearance and
the floor widens. The unilateral complete cleft is
function.
thus a full-thickness palatal defect of nasal
–– In expert hands, myocheiloplsty tech-
mucosa, bony palate, velar muscles, and oral
niques can give excellent results, but it
mucosa.
is also true that the fourth dimension can
In bilateral complete cleft lip and palate, the
negatively affect the morphological
premaxillary segment containing the central and
result of primary surgery. In these cases,
lateral incisor roots is discontinuous from the
secondary surgery becomes necessary.
alveolar arch. The abnormal anterior projection
of the premaxilla complicates the lip reconstruc-
tion because of the greater tension on the soft tis-
Palatoplasty: The goal of the cleft palate sues, risk of anterior fistulas with speech and
repair is to separate the oropharynx from the nasal regurgitation problems, and midface growth
nasopharynx, obtain normalization of speech, deficiency (common sequela of bilateral cleft
improve otologic issues, and minimize the effects palate).
of surgery on midfacial growth. Anatomic vari- The levator palatini muscle runs longitudi-
ability of cleft palate influences the timing and nally along the cleft margin before it inserts aber-
sequence of surgical repair. Usually, if there is rantly into the posterior border of the hard palate
cleft palate with cleft lip and alveolus (complete (Fig. 12.5); this results in ineffective contraction
cleft lip and palate), the repair of the hard palate and inability to close the palate against the poste-
will be done at the time of lip repair, while soft rior pharyngeal wall. Air escape through the nose
palate repair will be done later. If cleft palate during speech produces a characteristic hyperna-
involves only the secondary palate, reconstruc- sal quality. In addition, aberrant levator position-
tion will be done at the same time for the hard ing impairs the function of the tensor palatini
and soft palate. muscle, which normally assists eustachian tube
Optimal timing of palate repair must be bal- function [46].
anced between optimal speech outcome and In the cleft of the secondary palate, dentition
optimal maxillary growth. However, the pri- is normal and symmetric and the levator palatini
mary goal is to attain a normal speech (primary muscles are displaced as in the complete clefts. If
goal). Good speech outcomes become more dif- submucous cleft palate is present, there is muco-
ficult to achieve with increasing age, whereas sal continuity with or without bifid uvula.
most maxillary growth problems can be The purpose of the palate repair is to obtain
addressed with orthodontic treatment and max- complete nasal and oral tension-free closure and
illary osteotomies. restoration of normal muscle anatomy.
190 M. Zama and M. I. Rizzo
ment can be performed. Nutritional issues can –– During infancy, lower lid reconstruction (if
necessitate alternative enteral feeding or gas- the lid insufficiency does not allow the eyelid
trostomy. A shunt can treat hydrocephalus closure) and ear reconstruction (to treat micro-
when present. Early cranioplasty is debated. tia) can be performed.
Surgeons who perform anterior vault remodel- –– Bone graft on the midface and orthognathic
ing with fronto-orbital advancement after surgery are deferred until late adolescence or
6 months of age may first expand the posterior early skeletal maturity.
skull earlier in life (3–6 months of age) if there –– Rhinoplasty and fat grafting generally con-
is severe progressive turribrachycephaly. clude the treatment.
This is the typical protocol for Apert or
Crouzon patients: In less severe Pierre Robin sequence, the first
–– Age 4 months: poster fossa expansion treatment is the prone positioning until 6 months
through distraction osteogenesis. to allow neuromuscular adaptation and mandibu-
–– Age 12 months: fronto-orbital advance- lar growth. In the more severe forms, the airway
ment if ocular proptosis still present. obstruction imposes an early mandibular length-
–– Age 6–8 years: Monobloc fronto-facial ening by distraction osteogenesis, performed to
advancement, with or without facial prevent tracheostomy. Tracheostomy is reserved
bipartition, through distraction osteogene- for syndromic patients or for those with associ-
sis (which is gold standard for children with ated anomalies such as tracheomalacia. Tongue–
deficient supraorbital rim, short anterior lip adhesion could be indicated in a few selected
cranial base and orbits, retruded maxilla, cases but actually almost abandoned. If cleft pal-
and class III anterior open bite) (Figs. 12.16 ate is present, the correction is performed
and 12.17); Le Fort III osteotomy through between 6 and 9 months of age.
distraction osteogenesis is an alternative in In craniofacial microsomia and hemifacial
few selected cases (Fig. 12.18). microsomia, the treatment is centered around the
–– Age 15 years: Le Fort I osteotomy through three major components of the syndrome: ear,
distraction osteogenesis. mandible, and soft tissue.
–– Age 18–20 years: possible redo of Le Fort Reconstruction of external ear is performed by
I osteotomy through distraction costal cartilage (especially in Europe) or polyeth-
osteogenesis. ylene implant (mainly in the United States), as
• At the age of skeletal maturity, improving explained in the next section.
facial appearance can be achieved through rhi- The major difficulty in major reconstruction
noplasty, genioplasty, bone graft augmenta- planning is the mandible. Mandibular distraction
tion, fat graft, and other ancillary procedures. osteogenesis has been a major advance in pro-
viding an opportunity for early skeletal recon-
In Treacher–Collins–Franceschetti syndrome struction so that soft tissue reconstruction can
(bilateral Tessier no.6–8 craniofacial cleft), there proceed at a relatively early age. Mandibular dis-
is great controversy about the timing of surgical traction can be employed at any age from the
treatment, and multiple protocols are published. neonate to the adult. The technique involves
Tessier stated that it is better to delay major complete osteotomy of the mandible with the
reconstruction until the age of 6–10 years because application of intraoral distraction devices
resorption of bone grafts is more severe in this (extraoral devices are now almost abandoned)
than in other malformations. A staged approach that can be activated at the rate of 1 mm/day.
to reconstruction is more appropriate: Mandibular distraction can be secondly repeated.
12 Craniofacial Malformations 195
Maxillo-mandibular distraction is also possible When absent, the ramus of the mandible can be
by performing a concomitant LeFort I osteotomy reconstructed by a costochondral graft or free
and placing an internal device that proceeds as a fibula flap.
mandibular distraction. These procedures must The treatment more accepted for soft tissue is
be coordinated with orthodontic treatment. fat grafting.
196 M. Zama and M. I. Rizzo
Fig. 12.18 LeFort III osteotomy and advancement, pre- and postoperative
12 Craniofacial Malformations 197
12.12 Ear Reconstruction formed at a younger age (e.g., 5 years old). The
techniques consist in the insertion of the implant
Total ear reconstruction for microtia is performed (after union of a base and a helicoidal rhyme, on
by autologous costal cartilage or porous polyeth- the model of the contralateral ear), raising of the
ylene implants. Among the major difficulties in superficial temporal fascia flap, and harvest full-
reconstruction of microtia is the short position of thickness skin grafts (Fig. 12.20).
the hairline. This is related to the soft tissue defi- In expert hands, both techniques produce good
ciency and the underlying skeletal asymmetry results, but both have important limitations. The
and can require the positioning of a skin expander gold standard of the ear reconstruction will be
for hairline repositioning before ear reconstruc- reached when 3D printing of autologous cartilage
tion. In both techniques, the lobule is recon- will be available.
structed from the microtic ear.
The reconstruction by cartilage requires the
harvesting of VI, VII, VIII, and, in some cases, IX 12.13 Glossectomy
costal cartilages. These are sculpted and united to for Macroglossia
create the three-dimensional contours of the ear
(on the model of the contralateral ear) and are Macroglossia is defined as a tongue that in the
placed under local skin flaps (Fig. 12.19). resting position protrudes beyond the teeth
Autologous reconstruction of microtia with a toward the alveolar ridge. It is a typical feature of
sculpted costochondral graft is classically per- the Beckwith–Wiedemann syndrome (97%) and
formed in staged procedures, as originally may cause a functional and esthetic abnormality
described by Tanzer. Then Brent, Nagata, and with problems in speech, chewing, swallowing,
Firmin modified the methods to achieve finer and suction. Moreover, it can cause upper airway
results in fewer stages. Today this reconstruction obstruction and obstructive sleep apnea
is performed in two steps: (1) cartilage sculpting syndrome.
and inset; and (2) restoration of the retro-auricular Therefore, children with macroglossia should
sulcus. Nagata recommends waiting until have formal evaluations for potential effects on
10 years of age to allow the rib cartilage to feeding, speech, and sleep. This evaluation deter-
achieve adequate cartilage volume and stiffness. mines the indication of the partial glossectomy,
The reconstruction by porous polyethylene, which is the reduction of less than one-half
first described by Reinisch, can even be per- tongue. The simplest approach is transoral.
Fig. 12.19 Ear reconstruction by cartilage: pre- and postoperative, and contralateral ear
198 M. Zama and M. I. Rizzo
Fig. 12.20 Ear reconstruction by polyethylene and superficialis temporal fascia: pre- and postoperative, and contralat-
eral ear
11. Kernahan DA. The striped Y: a symbolic classifica- 31. Feldman GJ, Ward DE, Lajeunie-Renier E, et al. A
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1971;47:469. niofrontonasal syndrome maps to Xp22. Hum Mol
12. Witt PD, Rapley J. Classification, varieties, and Genet. 1997;6:1937–41.
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SJ, Hentz VR, editors. Plastic surgery, vol. 4. 2nd ed. of anotia and microtia. J Med Genet. 1996;33:
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of cleft lip and palate. Plast Reconstr Surg. 1962;29:31. try in hemifacial microsomia. Plast Reconstr Surg.
17. Kahn DM, Schendel SA. Anatomy and classification 1973;52:221.
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200 M. Zama and M. I. Rizzo
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 201
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_13
202 G. E. Pajardi et al.
These options include splinting, stretching, phys- will provide superior outcomes by addressing all
ical therapy, and prosthesis for increased function aspects of the physical and emotional state of
and cosmesis [1]. both the patient and the family.
Therefore, successful technical reconstruction
may fail to alter already established fixed func-
13.3 Epidemiology tional or psychological patterns if the reconstruc-
tion is not completed by approximately 4 years of
Congenital hand conditions are common, occur- age. Ideally, reconstruction should be completed
ring in 2.3 per 1000 of total births or 0.16% by school age to allow for easier social
–0.18% of the population of the United States, transitioning.
with incidence varying according to region and
ethnicity. Ekblom et al. reported a worldwide
incidence of 21.5 per 10,000 live births. Lamb 13.4 Embryology of Limb
et al. and Giele et al. reported the overall preva- Development
lence of congenital hand anomalies to be 11.4–
19.7 per 10,000 live births. Of the anomalies During embryonic development, the upper
included, failure of differentiation is the most extremity develops from the arm bud, a mass of
commonly reported, followed by failure of dupli- mesoderm-derived mesenchyme covered by
cation and failure of formation anomalies. ectoderm. The Hox genes (HoxA, HoxB, HoxC,
Polydactyly is the most common individual diag- and HoxD) are responsible for regulating limb
nosis. Although overall only slight variation development in the human embryo. Sonic
exists in the prevalence of major anomalies hedgehog, fibroblast growth factor, and Wnt-7a
among different regions or ethnic populations, are some of the known signaling proteins that
there are exceptions. For example, ring constric- control Hox gene expression. Hox gene prod-
tion syndrome is 4 to 6 times more prevalent in ucts act on competent mesenchymal cells within
Japan than in Scotland. Ulnar polydactyly is the limb bud, guiding these cells to form con-
more common among those of African descent. densations at the appropriate time and location.
In general, males are more likely to be affected These condensations form the precartilaginous
by congenital hand anomalies than females with skeletal foundation of the limb. The limb must
an overall ratio of 3:2. The prevalence of congen- form simultaneously across three anatomical
ital hand anomalies increases with maternal age. axes: proximal to distal axis, dorsal to palmar
Mothers older than 40 years are twice as likely to axis, and anteroposterior (preaxial/ postaxial)
have a child with hand deformity than mothers axis. The apical ectodermal ridge forms as a
younger than 30 years, 5–20% of upper limb thickening of ectoderm at the leading edge of
anomalies occur as a part of a known syndrome, the limb bud and, through its interactions with
and 50% occur bilaterally. Up to 17% of patients the underlying mesenchymal cells, is responsi-
will present with multiple upper limb anomalies, ble for proximal to distal differentiation of the
and up to 18% of patients will die before the age limb. The dorsal ectoderm helps to control the
of 6 years because of other concurrent congenital dorsal to palmar axis of differentiation, leading
disorders [5]. to distinct flexor and extensor surfaces of the
Because limb formation occurs concurrently hand and arm. The zone of polarizing activity is
with other organ development, it is important to a condensation of mesenchymal cells on the
be aware of associated abnormalities, including preaxial surface of the limb bud. This zone sig-
cardiac, hematopoietic, or tumorous conditions. nals the anteroposterior formation of the limb
Communication with the pediatrician is impor- bud by setting up a gradient of signaling pro-
tant in establishing a comprehensive diagnosis teins along this axis. The arm bud begins as an
and for staging and planning of any reconstruc- outgrowth from the ventrolateral wall of the
tive procedures. A multidisciplinary approach developing embryo and appears at approxi-
13 Malformations of the Hand 205
13.5.3 T
ransverse Arrest of the Digits 1978. In 1995, Vilkki reported a series of 18
Distal to the Metacarpal Level successful congenital toe transfers, with an
11-year follow-up proving that toe transfer was
Transverse arrest of the digits distal to the meta- beneficial in this population. Several congenital
carpal level, sometimes referred to as sym- anomalies have been treated with toe transfer,
brachydactyly, has been treated by conventional including transverse deficiency, longitudinal
techniques of distraction lengthening and non- deficiency, traumatic amputation, vascular mal-
vascularized toe phalangeal bone grafting. formations, and constriction ring syndrome.
Metacarpal or phalangeal lengthening uses the Studies have shown that growth potential is
principles of distraction osteogenesis to form retained in the transferred toe. Epiphyseal plates
new bone. A distractor is placed spanning a remain open, and bone growth is comparable to
metacarpal or phalangeal osteotomy or corti- that of the corresponding toe on the contralat-
cotomy, and the bone is distracted 0.5–1 mm per eral foot. A long- term study of toe-to-hand
day for 3–6 weeks until the desired digit length transfers in post-traumatic deformities has
is achieved. The bone gap may consolidate with shown good hand function and acceptance of
regenerate bone or may require secondary the transferred digit up to 20 years after the pro-
autogenous or allograft bone grafting. cedure. Transverse deficiency of the thumb is an
Transverse deficiencies of the digits may also be ideal indication for free microvascular toe-to-
treated with nonvascularized toe phalangeal hand transfer. Unlike longitudinal thumb defi-
bone grafting from the proximal phalanges of ciencies, the proximal thumb remnant tends to
the second, third, or fourth toe. Up to 1.5 cm of retain some normal anatomy, including a mobile
length can be achieved with each proximal pha- carpometacarpal joint, thenar muscles, and
lanx graft. Whether the epiphysis of a toe pha- proximal stumps of the flexor pollicis longus
langeal bone graft continues to grow remains and extensor pollicis longus tendons. In such
controversial. It has been recommended that toe cases, a microsurgical second toe-to-thumb
phalangeal bone grafts should be performed transfer is a better option than pollicization of
before 15 months of age, that the bone should be the index finger. In children with a thumb but
harvested extraperiosteally, and that the collat- the absence of all four fingers or with the com-
eral ligaments and tendons should be reattached plete absence of all five digits, bilateral second
to provide the optimal conditions for the physis toe transfers can be performed. The two toe
to remain open and thus maintain growing transfers can provide three post pinch to a
potential. Free microvascular toe-to-hand trans- remaining thumb or one toe transfer can be used
fer is becoming an increasingly accepted method to reconstruct the thumb and the other toe trans-
for treatment of these patients. The first toe-to- fer can be used to create a digit for pinch activ-
hand transfer was performed by Nicoladoni in ity. The child’s family should be carefully
1897 for a traumatic thumb amputation and counseled regarding the limitations and poten-
required multiple stages to preserve the blood tial complications before proceeding with this
supply to the transferred toe. In 1955, Clarkson extremely difficult reconstruction [14, 15].
reported the first series of congenital toe-to-
thumb transfers with 15 transfers in six patients.
Because multiple stages required immobiliza- Tips and Tricks
tion of the hand to the foot, the procedure fell • Toe phalangeal bone grafts should be
out of favor. The first successful microvascular performed before 15 months of age.
toe-to-hand transfer was reported by Cobbet in • The bone should be harvested
1969 and led to the possibility of free toe trans- extraperiosteally.
fers for congenital malformations. The first toe- • The collateral ligaments and tendons
to-
hand transfer to reconstruct a congenital should be reattached.
anomaly was performed by O’Brien et al. in
13 Malformations of the Hand 207
13.5.4 F
ailure of Formation of Parts: of the forearm and insert into the ulna, causing
Longitudinal Arrest severe bowing. The ulna may also be short, and
the distal humerus is often hypoplastic, leading to
13.5.4.1 Radial Longitudinal stiffness of the elbow. Both the radial artery and
Deficiency radial nerve may be absent. The median nerve is
Radial longitudinal deficiency, or radial club always present and courses superficially below
hand, involves approximately 1 in 30,000 to 1 in the skin in the radial concavity, making it prone
100,000 live births and is more common in boys to injury during operative exposure. Radial longi-
than in girls and affects Caucasians more often tudinal deficiency results in very poor function in
than other races. The deformity is bilateral up to the affected hand because of the flexed position
50% of the time and, when unilateral, affects the of the radially deviated hand, loss of wrist sup-
right side more often than the left (Fig. 13.1a, b). port, poor flexor/extensor tendon excursion,
Radial longitudinal deficiency is often found hypoplasia of the thumb, and stiffness of the
in association with other malformations of the elbow. These deformities increase with age, lead-
hematopoietic, cardiac, genitourinary, and skele- ing to deteriorating function. Psychologically, the
tal systems, including Fanconi anemia, TAR syn- appearance of the hand can be quite troubling for
drome (thrombocytopenia, absent radius), both the child and the parents. For these reasons,
Holt–Oram syndrome (cardiac defects), and the treatment should be done immediately after birth
VATER association (vertebral anomalies, anal and consists of passive stretching exercises and
atresia, tracheoesophageal fistula, renal defects). serial casting to begin, centralizing wrist and
Radial longitudinal deficiency has been classified hand on the remaining ulna. Contraindications to
into four types based on the severity of the treatment include older patients who have
involvement of the radius. Thumb hypoplasia is adapted to their deformity and children with stiff
often present, ranging from slight to total absence. elbows. In these circumstances, the radial angula-
The scaphoid and trapezium may also be absent. tion of the hand and carpus makes feeding and
Radial sided digits often exhibit a flexion defor- hygiene possible in the presence of a stiff elbow.
mity or camptodactyly. The small finger is often Surgical treatment of radial longitudinal defi-
unaffected, with relatively normal function. ciency attempts to improve the appearance and
Short, fibrotic muscles run along the radial side function of the hand by stabilizing the carpus on
a b
Fig. 13.1 Radial longitudinal deficiency; (a) clinical picture, (b) post-operative x-ray
208 G. E. Pajardi et al.
the end of the ulna. Historically, centralization of hypoplasia of the ulna with an intact epiphysis to
the carpus over the ulna and bone grafting of the total absence of the ulna with radiohumeral syn-
absent radius have been attempted, but central- ostosis. In all cases, a fibrous anlage tether
ization of the carpus only on the ulna remains the replaces the missing ulna and inserts into the
definitive treatment. Centralization is usually ulnar aspect of the carpus or the distal radius
performed in the first year through a Z-plasty epiphysis. The flexor carpi ulnaris is absent, the
incision over the radial aspect of the wrist to ulnar and median nerves are present, but the ulnar
release the tight skin envelope. After identifying artery is often absent. Unlike radial longitudinal
the median nerve, the carpus is freed from the deficiency, the wrist is stable, allowing for rela-
radial fibrotic muscle mass and then centralized tively normal digital function. The radial head
over the ulna after transecting the brachioradialis, may be dislocated, leading to pain or loss of func-
flexor carpi radialis, and extensor carpi radialis tion at the elbow. With the most severe deficien-
longus tendons. The lunate may need to be cies, the humerus is internally rotated and the
excised to fit the carpus over the end of the ulna. forearm pronated, compromising the positioning
A longitudinal Steinmann pin is used to hold the of the hand. Treatment of ulnar longitudinal defi-
middle finger metacarpal bone and carpus over ciency consists of serial casting to improve the
the ulna for several months. Radial deforming wrist and elbow positions. Excision of the anlage
tendons such as the flexor carpi radialis may then is indicated for greater than 30 degrees of
be transferred to the extensor carpi ulnaris to help angulation or when the deformity is progressive.
rebalance the carpus [2]. The anlage is approached through a lazy-S inci-
sion and resected off from the carpus or distal
radius. Kirschner wires may be used to hold the
Tips and Tricks
wrist in a neutral position. Tendon transfers are
Buck-Gramcko has advocated radialization
not required; however, in severe bowing, a radial
of the carpus in which the deformity is
osteotomy may be required to help straighten the
overcorrected to the ulnar side by placing
long axis of the forearm. When there is a loss of
the ulna along the axis of the index finger
function at the elbow, the proximal radial head is
metacarpal bone. Preoperative distraction
resected, and a one-bone forearm is created by
may be performed initially to allow the car-
osteosynthesis of the distal radius to the proximal
pus to be radialized or centralized without
ulna. In the case of radiohumeral synostosis, a
the need for resection of carpal bones. If
derotational osteotomy of the humerus may be
significant ulnar bowing is present, a cor-
required to place the hand into a more functional
rective osteotomy or multiple osteotomies
position. Arthroplasty of the elbow is not advised
may also be performed and fixed with the
because of the low likelihood of success [16].
same Steinmann pin to help straighten the
long axis of the forearm.
13.5.4.3 Central Ray Deficiency
Central ray deficiency, or cleft hand, was origi-
nally classified as either typical or atypical.
13.5.4.2 Ulnar Longitudinal Typical (true) cleft hand is caused by failure of
Deficiency development of the central digit of the hand, the
Ulnar longitudinal deficiency occurs in 1 in every middle finger, including the metacarpal bone,
100,000 live births. The deformity is often spo- which leads to a deep V-shaped cleft. The border
radic and does not have the syndromic associa- digits are occasionally involved in syndactyly
tions of radial longitudinal deficiency. However, with a tight first web space. Transverse bones
approximately 50% of the patients will have separating the index and ring fingers are often
some type of musculoskeletal abnormality, present. Atypical cleft hand is now considered to
including the contralateral upper limb or the be a variant of symbrachydactyly. The central
lower limbs. There is a clinical spectrum from digits of the hand are shortened or absent, with
13 Malformations of the Hand 209
vestigial nubbins remaining. The “cleft” is broad dle fingers. Children with a complete absence of
and flat, unlike the V-shaped cleft of typical cen- the thumb may develop pronation of the index
tral ray deficiency, usually leaving a thumb and finger for the same reason. Therefore, treatment
ulnar border digits. Cleft hand is usually inher- is often recommended by the second year to
ited as an autosomal dominant trait, with reduced establish more normal prehensile patterns. The
penetrance and variable expressivity among fam- Blauth classification is used to categorize thumb
ily members. There may be associated abnormal- hypoplasia. Type I is a slightly shorter normal
ities, including cardiac, visceral, ocular, auditory, functioning thumb and does not require any
and musculoskeletal, including cleft feet. Manske treatment. Types II and IIIA, in which the carpo-
and Halikis have classified cleft hands based on metacarpal joint is stable, can be treated with
the involvement of the first web space, which is deepening of the first web space and a tendon
the most predictive factor of hand function and transfer to improve opposition. The web space
therefore helps guide surgical treatment. Flatt is deepened by a traditional four-flap Z-plasty
described cleft hand as a “functional triumph but procedure [21].
a social disaster.” Treatment is directed at clos- The Huber transfer uses the abductor digiti
ing the cleft to improve the appearance of the minimi to recreate the thenar eminence and
hand and to treat any syndactyly that may exist. replace the hypoplastic intrinsic muscles. The
Transverse bones are removed from within the flexor digitorum superficialis from the ring finger
cleft, as these will continue to grow and push the may also be transferred through a window in the
cleft farther apart with age. If the ulnar border transverse carpal ligament to restore thumb oppo-
digits are syndactylized, they can be released at sition. Types IIIB, IV, and V require complete
the time of cleft closure [17–20]. reconstruction because of an unstable or absent
carpometacarpal joint. Index finger pollicization
is the treatment of choice for these children
Tips and Tricks (Fig. 13.2a, b) [22].
The Snow–Littler procedure may be used Pollicization was originally described by
to release the first web space syndactyly by Littler and modified by Buck-Gramcko. In this
releasing the thumb from the index finger technique, skin flaps are designed to widen the
and then transposing the index finger ray web space between the new thumb and middle
onto the middle finger metacarpal remnant, finger. The index finger is elevated as an island
thereby achieving web release and cleft flap on its radial and ulnar neurovascular pedi-
closure simultaneously. Alternatively, clo- cles, dorsal veins, and tendons. An osteotomy of
sure of the cleft by transposition of the the second metacarpal bone at the level of the dis-
index finger into the middle finger position tal epiphyseal plate is performed, and the metaph-
as described by Miura and Komada could yseal flare at its base and the intervening shaft are
be used and may be technically simpler. removed. The finger is pronated between 140 and
160 degrees, and the metacarpal bone is placed in
45 degrees’ abduction palmar to the base of the
13.5.5 Undergrowth index finger metacarpal bone. The metacarpal
head then becomes the new carpometacarpal
13.5.5.1 Hypoplastic Thumb joint. The first dorsal interosseus muscle is reat-
Hypoplastic thumb may also be characterized as tached to become the abductor pollicis brevis, the
a variant of radial longitudinal deficiency and is first palmar interosseous muscle becomes the
often associated with radial club hand. Children adductor pollicis, the index extensor digitorum
with a hypoplastic thumb may begin to develop communis functions as the abductor pollicis lon-
a widening of the second web space to achieve gus, and the extensor indicis proprius becomes
rudimentary pinch between the index and mid- the extensor pollicis longus [23].
210 G. E. Pajardi et al.
a b
Fig. 13.2 Hypoplastic thumb; (a) pre-operative picture, (b) Pollicization: immediate post-operative result
a b c
Fig. 13.3 (a, b) preoperative drawing, (c) immediate postoperative result Syndactyly
(Fig. 13.3a, b, c), may allow separation of the ment. Extreme pronation or supination that inter-
digits and deepening of the web space without feres with function is an indication for surgery. In
requiring full-thickness skin grafts [24–28]. addition, a forearm fixed in greater than 60
degrees of pronation generally requires surgery.
Derotational osteotomy either at the site of syn-
Key Points
ostosis or in the diaphysis of the radius and ulna
Surgical release of syndactyly should be
to fix the forearm in neutral or slight pronation
performed as early as possible to allow nor-
has been advocated. However, resection of the
mal growth of the digits and normal grasp
synostosis and interposition of autologous tissue
and pinch.
or allograft between the radius and ulna is
favored. However, separation is tenuous, as the
synostosis tends to recur. Many interposition
13.5.6.2 Radioulnar Synostosis
materials, to place, at the time of separation have
Congenital proximal radioulnar synostosis results
been studied, including synthetic materials,
from the failure of developing cartilaginous pre-
autologous tissues, and allograft tissue. Synthetic
cursors of the forearm to separate late in the first
materials, such as silicone and polyethylene
trimester. It is bilateral in 60% of all patients. The
sheeting, and autologous tissues (i.e., nonvascu-
incidence is unknown, and in most cases, it
larized or vascularized tissue), such as free fat
occurs sporadically, but it can be inherited as an
grafts, radial forearm fascial flap, and free lateral
autosomal dominant trait with variable pene-
arm adipofascial flap, have been used. In addi-
trance. Children usually present between 2 and
tion, some surgeons have recommended periop-
6 years of age, with the absence of forearm rota-
erative irradiation, although this is usually used
tion and a slight elbow flexion contracture.
for post-traumatic radioulnar synostosis [29, 30].
Children are often at school age before a diagno-
sis is made; this is due to the fact that the wrist
has the ability to compensate for the lack of pro- Key Points
nation/supination of the forearm. Clinical suspi- Extreme pronation or supination that inter-
cion warrants radiographs of the forearm, which feres with function is an indication for
reveal the proximal radioulnar synostosis. The surgery.
radial head is often subluxed or dislocated. Surgery is recommended when the fore-
Surgical management depends on the severity of arm is fixed in pronation >60°.
the synostosis and the resulting functional impair-
212 G. E. Pajardi et al.
13.5.6.3 Symphalangism
Symphalangism is the term used to describe the
failure of interphalangeal joint development and
fusion of the proximal phalanges to the middle
phalanges and was first described by Cushing in
1916. This condition represents 1% of all con-
genital upper extremity anomalies and is fre-
quently transmitted as autosomal dominant. Flatt
and Wood classified symphalangism as true sym-
phalangism without additional skeletal
abnormalities, symphalangism associated with
symbrachydactyly, or symphalangism with syn-
dactyly. Clinically, there is the absence of motion,
and there are not skin creases in the affected dig- Fig. 13.4 Preaxial polydactyly or thumb duplication
its. The proximal interphalangeal joint does not
develop with growth. The affected fingers do Both the radial and ulnar duplicated thumbs
have some flexion, as the metacarpophalangeal show some degree of hypoplasia, although the
and distal interphalangeal joints are present and radial duplicate is usually more affected. Wassel
have a normal range of motion. Attempts have has categorized thumb duplication into seven
been made to reconstruct or replace the proximal types. Type I is characterized by a bifid distal
interphalangeal joints, but results have not been phalanx, whereas type II is a duplication at the
favorable. If a child has a poor grasp secondary to level of the interphalangeal joint. Type III is a
symphalangism, a wedge of bone can be removed bifid proximal phalanx, and type IV, the most
from the level of the proximal interphalangeal common, is a duplication at the level of the meta-
joint and the phalanges fused in 45 degrees of carpophalangeal joint. Type V is characterized by
flexion. a bifid metacarpal, and type VI is a duplication at
the level of the carpometacarpal joint. Type VII
describes thumb polydactyly with an associated
13.5.6.4 Duplication (Polydactyly) triphalangeal thumb. Treatment of thumb poly-
Polydactyly can occur on the preaxial (radial) or dactyly is based on the type of duplication. Types
postaxial (ulnar) side of the limb or centrally, I and II can be treated with either resection of the
with postaxial polydactyly being the most com- radial duplication or central resection (Bilhaut
mon type. Preaxial polydactyly is more common operation) from each of the duplicated thumbs
in white population, and postaxial polydactyly is while preserving their outer portions. Unbalanced
more common in African Americans. The super- thumbs are generally managed with resection of
numerary digit in postaxial polydactyly is either the radial duplication, and balanced thumbs are
well developed (type A) or rudimentary and managed with central resection. Treatment of
pedunculated (type B). Those that are rudimen- duplication types III and IV must be individual-
tary and represent a small nubbin of tissue can be ized. In general, the best phalangeal portions of
managed by ligating the base of the pedicle in the both thumbs are incorporated to create the best
nursery. This will lead to necrosis of the nubbin, thumb. The radial duplication is usually ampu-
which will eventually fall off. The more devel- tated, as it is less developed, followed by radial
oped type A digits require formal surgical abla- collateral ligament reconstruction of the metacar-
tion and may require reattachment of the ulnar pophalangeal joint and reattachment of the thenar
collateral ligament at the metacarpophalangeal muscle insertion to the radial base of the proxi-
joint or the abductor digiti quinti tendon. Preaxial mal phalanx of the remaining thumb. Treatment
polydactyly or thumb duplication occurs in 8 in of types V and VI involves amputation of the
100,000 births (Fig. 13.4). radial duplication along with intrinsic muscle
13 Malformations of the Hand 213
a b
Key Points
Surgical options include debulking of the
digit and/or disrupting further growth by
obliterating the epiphyseal plates. Given
the difficulty of treating this anomaly and
the mediocre functional results, amputa-
tion should be strongly considered when
only one or two digits are involved. If
amputation is not warranted or if the par-
ents refuse, staged debulking may be
considered.
13.5.8 C
ongenital Constriction Ring
Fig. 13.6 Constriction ring, immediate post-operative
Syndrome result
13.5.8.1 Constriction Rings Constriction rings may also affect the underlying
Constriction rings may encircle a single digit or
nerves, necessitating decompression. In addition
multiple digits or the entire limb of a newborn,
to releasing the constriction ring, the skin and
causing varying degrees of vascular and lym-
subcutaneous tissues are rearranged with multi-
phatic compromise. Constriction rings occur in
ple Z- or W-plasties (Fig. 13.6). Some surgeons
1 in 15,000 births. The constrictions may be
advocate the release of constriction rings in two
either circumferential or incomplete and may
stages. Half of the circumference of the ring is
occur anywhere on the body, although the limbs
excised at the first stage, and the skin is length-
are most commonly affected. The cause of this
ened with multiple Z-plasties. The remaining
condition is not fully understood. According to
50% of the constriction ring is released in a simi-
the intrinsic mechanism, it is caused by a vascu-
lar manner at a second stage [39–41].
lar disruption in the embryo. According to the
extrinsic mechanism, amniotic disruption causes
the release of amniotic bands that encircle and
strangulate the limb or parts of a limb in utero. Tips and Tricks
Patterson classified constriction rings into four Constriction rings may be successfully
types. Type 1 is a mild transverse or oblique dig- released circumferentially around a limb or
ital groove. Type 2 is a deeper groove with an digit in a single stage.
abnormal distal part. Type 3 is characterized by If the constriction rings have transected
incomplete or complete syndactyly of the distal extensor or flexor tendons, reconstruction
parts, which is termed acrosyndactyly. Type 4 is with tendon grafts and/or tendon transfers
a complete amputation distal to the constriction. may be necessary.
Treatment of a digit or limb threatened at birth Amputation may occasionally be
by distal ischemia caused by a proximal con- required.
striction ring requires urgent release of the ring.
13 Malformations of the Hand 215
severe. Most surgeons advocate one-stage proce- considered correct and could in some way lead to
dures that address the bone, joints, and soft tis- problem resolution. They analyze results of sim-
sue, as this gives the best results [50–52]. ple observation, versus stretching and exercises,
versus night splinting with or without daily exer-
cises versus open surgery and find out that all the
13.5.10 Pediatric Trigger Finger
series lead in some way to different percentages
of clinical resolution, evidently in different peri-
Key Points ods of time treatment.
Trigger thumb is one of the most common Anyway investigating correctly the data, it is
pediatric hand conditions and responds evident that splinting or observations or stretch-
universally to simple surgical release. ing leads to a complete resolution preferentially
Trigger fingers are more complex, often in mild cases, and normally resolution is obtained
owing to systemic conditions or anatomical with longer treatments.
abnormalities, and consequently require a On the contrary, open surgery leads in the
wide and ample treatment. majority of cases to recovery in a shorter time
with really low rate or no complications.
Normally relatives willingly accept the period
of orthesis to try to have a simple way toward
resolution. Anyway usually, due to little compli-
13.6 Trigger Thumb ance of the babies and to a long treatment, rela-
tives usually switch happily to surgical
The etiology of trigger thumb in children solutions.
remains uncertain. The main accredited Surgery is quite simple; it could be performed
hypothesis is that there is an anatomical mis- under slight sedation and local anesthesia. It is
match between the diameter of the tendon performed through a small transversal incision at
sheath and the diameter of the flexor pollicis the MPJ volar surface of the thumb, the identifi-
longus (FPL) tendon. cation of the tight A1 pulley, and its surgical
The condition normally presents with fixed release. Often, it is possible to identify the Notta
flexed thumb interphalangeal joint (IPJ), with the nodule, but once the pulley is open, no proce-
presence of a small nodule on the volar face of dures are required on the nodule. Immediately
the metacarpophalangeal joint (MPJ), Notta nod- after the complete pulley release, the finger
ule. Sometimes it is possible to find some cases in shows a complete extension of IPJ [53, 54].
which the thumb is fixed in an extended position,
with no IPJ active flexion.
The relatives find the condition accidentally 13.7 Trigger Finger
because the triggering is painless.
Sometimes it is supposed to be the result of a Pediatric, or congenital, trigger finger presents as
trauma or of a subluxation, but normal radio- a digit, other than the thumb, that locks in
grams and ultrasound exclude it. Moreover, the flexion.
presence of Notta nodule is diriment. As pediatric trigger thumb, although described
Regarding treatment, there is no unique as congenital by some authors, there are no clear
direction. records of this condition being present at birth. It
Normally, instructions vary from a first period has been reported as presenting between the ages
of 3–6 months of splinting to open surgical of 3 weeks and 11 years. Many papers suggest
release in cases of splinting failure. that the pathological cause is due to anatomical
Exploring the literature, some authors sug- anomalies, but this does make it hard to explain
gested that all the therapeutic attitudes could be why the condition is not present at birth.
13 Malformations of the Hand 217
The management of this condition has varied The rehabilitation of the child involves not
from conservative splinting to operative explora- only the little patient but also his family and all of
tion and correction of the offending structures. the medical staff who will take care of his health
In the literature, there is confusion on out- as a team.
comes of splinting in trigger finger due to the The protagonist of the rehabilitation project is
fact that papers often compare the conservative not just the hand but the whole little patient in the
treatment of trigger thumb and trigger finger harmonious development of the evolutionary
together. stages happening in the family context.
What is clear from the literature is that etiol- The hand therapist builds an ad hoc path using
ogy of congenital trigger finger is different from his knowledge, cultural background, and experi-
congenital trigger thumb and adult conditions. It ence, but above all his own creativity and imagi-
is reported that anatomic mechanical condition, nation because it is important not to forget that
such as mutual relationships among flexor digito- the patient in this case is a child.
rum profundus (FDP)) and flexor digitorum In the specific area of pediatric hand affected
superficialis (FDS), or anatomical anomalies of by congenital malformation, rehabilitation must
pulleys, causes and sustains the triggering. The be offered in the form of a game, with suggestive
application of the operative principles applied in activities that try to involve and stimulate the little
pediatric trigger thumb and adult trigger finger patient. Playing thus becomes a fundamental tool
consisting in releasing of the A1 pulley only that the hand therapist has at his disposal; it must
could lead to insufficient results. therefore meet criteria not only of functionality but
Children who present with trigger fingers also of attractiveness and stimulus requirements
could have an underlying condition responsible for the attention and involvement of the child.
for the triggering. Triggering has been associated This is where the therapist has to use all his
with mucopolysaccharidosis, juvenile rheuma- creativity. There is no pathology-dependent or
toid arthritis, Ehlers–Danlos syndrome, Down predetermined activity for everyone, but, depend-
syndrome, and central nervous system disorders ing on the goal you want to achieve, the most
such as delayed motor development [55]. suitable game is identified. Many times observa-
Surgery is quite often indicated, and a step- tion and play turn out to be the key to rehabilita-
wise approach through Bruner’s incision is there- tion, always implementing new strategies and
fore necessary. proposals that attract the attention of the young
Surgery could be performed under soft seda- patient and that respect the developmental and
tion and local anesthesia. The surgical approach cognitive stages reached.
allows the possibility to have a complete view of Pediatric hand rehabilitation is not just “play-
the flexor apparatus; both tendon structures and ing” or “gymnastics,” as it is often defined, but a
the pulley system must be carefully analyzed, methodology that develops and supports the
and triggering must be evoked during surgery in child’s skills within specific and individualized
order to be sure that the procedure undertaken paths.
has eliminated each possible cause of tendon Treatment of upper limb malformations,
friction [56]. therefore, is part of a broad and rich context that
aims at the well-being of the child in his whole
being.
13.7.1 Physiotherapy
Aristotle defined the hand “the tool of tools.” The 13.7.2 Psychological Aspects
hand is for an individual a work, communication,
and cognitive tool, right from the prenatal life: Hands have a central role in social and emotional
through touch, we learn, discover, get excited, relationships because they vehicle emotionality;
and communicate. they are the protagonist in nonverbal communi-
218 G. E. Pajardi et al.
cation, but they are also constantly visible to oth- the medical care before and after surgery and at
ers as well as to their owner. When a person faces follow-ups.
trauma or malformation problems, this last aspect As expected, even the young patient must be
is really important from a motivational point of involved; this can be done in many different ways
view: the subject cannot avoid confronting his/ according to his/her age, since, based on it, the
her own difficulties and reactions raised in the relevant main topics will be different.
social context. During the interview between psychologist
Whether originated, the pathology of the and parents, it is really important to discuss this
upper limb affects and modifies many areas of topic in order to help parents in accepting the
individual life and requires an important psycho- child’s questions and supporting him/her during
logical effort of acceptance and adaptation. the inclusion in new contexts, for example, by
The relationship between patient and health talking and explaining to teachers and
specialists grows and shapes in this difficult con- educationists.
text, especially when patients are children. The attention of the psychologist must there-
Several observations proposed by psycholo- fore always be directed to the whole family sys-
gists, surgeons, and physiotherapists working on tem and its subsystems: the individual, the
this topic highlight the need for a synergistic couple, interpersonal, and the sibling systems.
approach involving different professionals. A multidisciplinary approach is essential con-
Emotional manifestations are common reac- sidering the complexity of congenital hand con-
tions to stressful events, and in most situations, ditions and hand diseases. The team has to deal
they can find support and reach acceptance carefully and respectfully with the patient and the
within the proposed therapeutic protocol. family, keeping in mind their needs.
However, if such emotions become stable and This requires that many professionals inte-
do not spontaneously evolve and resolve, it is grate together in order to provide a complete and
essential to evaluate the duration and intensity adequate response to a patient’s needs and not
of these emotions and their impact on quality of only to his/her malformed or traumatized hand.
life and therapeutic protocol. It is essential that
the psychologist attends during the first consul-
tation and then, subsequently, is available to the 13.8 Conclusions
patient or her/his family throughout the thera-
peutic protocol. Congenital differences of the upper limb repre-
The interview with the psychologist allows sent a significant and unique challenge for the
the patient to face emotional aspects, helping the hand surgeon. In all cases, the ultimate goal is to
child’s parents or the patient to expose and under- provide a functional limb that can be integrated
stand doubts and perplexities. Usually, uncertain- into the child’s overall development. This goal
ties concern aspects strictly related to the may be met surgically or through specialized
therapeutic options and protocol, but patients and therapy and rehabilitation. Every case is unique,
parents are also worried about life situations and each patient (and parent) will have a different
involving social skills, general child develop- capacity to adapt. These differences should be
ment—if the patient is a child, and educational taken into account before embarking on a long,
aspects. often difficult reconstructive course. It should be
The whole family is included in the therapeu- made clear from the outset that the child will
tic pathway starting from the psychological inter- never have a “normal” hand. Once realistic
view following the first medical examination expectations have been set, reconstruction and/or
with the surgeon and all the following access to rehabilitation can commence.
13 Malformations of the Hand 219
9. Swanson AB, Barsky AJ, Entin MA. Classification 29. Jones NF, Esmail A, Shin EK. Treatment of radioul-
of limb malformations on the basis of embryological nar synostosis by radical excision and interposition of
failures. Surg Clin North Am. 1968;48:1169–78. a radial forearm adipofascial flap. J Hand Surg [Am].
10. Temtamy SA, McKusick VA. The genetics of 2004;29:1143–7.
hand malformations. Birth Defects Orig Artic Ser. 30. Simmons BP, Southmayd WW, Riseborough
1978;14:1–619. EJ. Congenital radioulnar synostosis. J Hand Surg
11. Congenital Hand Committee of the JSSH. Modified [Am]. 1983;8:829–38.
IFSSH classification. J Jpn Soc Surg Hand. 31. Dobyns JH, Lipscomb PR, Cooney WP. Management
2000;17:353–65. of thumb duplication. Clin Orthop. 1985;195:26–44.
12. De Smet L. Classification for congenital anomalies 32. Bilhaut. Guerison d’un pouce bifide par un nouveau
of the hand: the IFSSH classification and the JSSH procede operatoire. Congr Franc Chir. 1890;4:576–80.
modification. Genet Couns. 2002;13:331–8. 33. Wassel HD. The results of surgery for polydactyly of
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Malformations of the External
Genitalia
14
Mario Zama, Maria Ida Rizzo, Martina Corno,
and Angelica Pistoia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 223
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_14
224 M. Zama et al.
ogy of external genitalia is critical to understand streak migrate around the cloacal membrane to
and repair all the possible malformations [3, 4]. form a pair of slightly elevated cloacal folds that
The genital system is embryologically and merge cranially into a single protuberance: the
anatomically connected with the urinary system. genital tubercle (GT), made up by all three germ
Both develop from a common mesodermal ridge layers. Caudally these folds develop into the ure-
(intermediate mesoderm), and initially the excre- thral folds anteriorly and the anal folds
tory ducts of both systems end in a single open- posteriorly.
ing: the cloaca. The first stage of genital development, inde-
However, female and male genitalia have dif- pendent of hormones, consists in forming a ure-
ferent functions; the female one produces oocyte thral plaque in the midline of the genital tubercle.
and protects and nourishes the offspring until This occurs during the eighth and 12th weeks of
birth; the male one produces and deposes sperm. gestation in both male and female fetuses.
The genital apparatus consists of three distinct The development of the urinary and genital
organs, and all of them go through an indifferent system depends on the interaction between the
stage: gonads (testicles in males and ovaries in epithelial and mesenchymal layers that provide a
females), the external genitalia, and the genital continuous guide to regulate the evolution of the
ducts. structures.
During this process, other changes occur on
both sides of the urethral folds, forming two tis-
14.2.1 External Genitalia sue elevations, the genital bulges. These swell-
ings will become the scrotal swellings in the male
Development of the external genitalia is a com- and the labia majora in the female.
plicated process involving a constellation of indi- At the end of the sixth week, it is not yet pos-
vidual morphogenetic events. External genitalia sible to determine the sex of the fetus (Fig. 14.1).
consists of the penis, clitoris, labia majora and
minora, and scrotum [5].
14.2.3 Different Stage
14.2.2 Indifferent Stage Sex differentiation starts between the eighth and
ninth weeks of gestation when the complicated
In the third week of development, mesenchymal process begins. This phase involves many genes,
cells originating in the region of the primitive but the essential one is found in the Y chromo-
a b c d
Urethral meatus
Fig. 14.2 Development of male external genitalia. (a) ing the penile urethra from proximal to distal and the solid
Differentiation of the genital tubercle, the urethral groove, epithelial cord that forms the external urethral meatus; (d)
urethral fold, and scrotal swellings; (b) frontal vision of final aspect of penis. (Illustrations by Angelica Pistoia)
the urethral folds closing over the urethral plate; (c) creat-
some, the SRY gene (sex determination region on as anogenital distance), followed by a rapid
Y). The product of this gene is a transcription lengthening of the genital tubercle, which is now
factor that initiates a cascade of activation of sev- called phallus. During this lengthening, the ure-
eral other genes, such as SF1 (steroidogenesis thral folds are stretched to form the lateral walls
factor) and SOX9 that stimulate the differentia- of the urethral groove without reaching the glans.
tion of Sertoli and Leydig cells in the testicles. The epithelial lining of the furrow, which origi-
The SRY protein is the factor that determines tes- nates in the endoderm, forms the urethral plate.
ticular differentiation [2], hormone production, At the end of the third month, the two urethral
and therefore the development of the male sex folds close over the urethral plate, from proximal
[6]: Leydig cells differentiate in the testis and to distal to form a large, diamond-shaped urethral
begin to secrete testosterone that stimulates the furrow inside the penis shaft (opening hinge),
development of mesonephric ducts (vas deferens until they merge on the middle (closing hinge),
epididymis). MIS (Mullerian inhibitor substance) creating the penile urethra.
produced by Sertoli cells in the testicles causes The most distal portion of the urethra is
the regression of paramesonephral ducts (female formed during the fourth month, when the ecto-
duct system). Dihydrotestosterone is responsible dermal cells of the tip of the glans penetrate
for the masculinization of genital tubercle, ductus inward and form a short epithelial cord, which
Wolffiano, and urogenital sinus (UGS), stimulat- then turns into a lumen, forming the external ure-
ing the development of external genitals, penis, thral meatus (Fig. 14.2).
scrotum, and prostate. The scrotal genital swellings arise in the groin
region and move caudally during development.
14.2.3.1 External Genitalia in Male Each swelling forms half of the scrotum and is
After androgen production, one of the first signs separated from each other by the scrotal septum.
of masculinization is the increase in the distance Toward the end of the second month, the uro-
between the anus and genital structures (known genital mesentery, which binds the testicle to the
226 M. Zama et al.
posterior abdominal wall, becomes ligamentous migrate through the inguinal canal at week 28
in the lower portion forming the caudal genital reaching the scrotum at the 33th week. The pro-
ligament. In the lower part of the testicle, a mass cess is influenced by increased intra-abdominal
of mesenchymal cells, rich in extracellular matri- pressure due to the growth of organs, hormones,
ces, called gubernacle, ends in the inguinal region including androgens, and MIS.
between the oblique abdominal muscles. The
peritoneum forms an eversion on each side of the 14.2.3.2 External Genitalia
midline in the ventral abdominal wall. This evag- in the Female
ination, the processus vaginalis (which covers the Estrogens stimulate the development of the exter-
testicle and becomes the tunic vaginalis), follows nal genitalia of the female. The genital tubercle
the course of gubernaculum testis into the scrotal elongates only slightly and forms the clitoris; ure-
swellings and is accompanied by the muscle and thral folds do not fuse, as in the male, but develop
fascial layers of the body wall form the inguinal into the labia minora. Genital swellings enlarge and
canal. Thus, the transversalis fascia forms the form the labia majora. The urogenital groove is
internal spermatic fascia, the internal abdominal open and forms the vestibule. During the third and
oblique muscle gives rise to the cremasteric fas- fourth months of gestation, errors in ultrasound sex
cia and muscle, and the external abdominal identification are possible because the GT is larger
oblique muscle forms the external spermatic fas- than in the male during the early stages of develop-
cia. The testicle descends through the inguinal ment. Errors in production of or sensitivity to hor-
ring, and the canal closes at birth or shortly after- mones of the testes lead to a predominance of
ward. Normally, the testicles reach the inguinal female characteristics under the influence of the
region around the 12th week of gestation and maternal and placental estrogens (Fig. 14.3).
a b
Genital
tubercle
Clitoris
Urethra
Urogenital
groove
Urethral
fold Vagina Labium
minus
Genital Labium
swelling majus
Perineum
Anus
14.3 Development of female external genitalia. (a) labia major. In the urogenital groove, there are the urethral
Genital tubercle enlargement and anus spacing; (b) the meatus and the vagina opening (Illustrations by Angelica
genital tubercle becomes the clitoris, the urethral folds Pistoia)
become the labia minora, and the genital swellings the
14 Malformations of the External Genitalia 227
• Female Malformation:
14.3 Risk Factors –– Ambiguous genitalia (genitalia not clearly
male or female).
Genital malformation, including hypospadias, rep- –– Imperforate hymen.
resents the second most common male birth defect –– Labial adhesions.
after cardiac malformations. During the past –– Genital organs joined together (fusion
50 years, hypospadias incidence has doubled abnormalities).
along with other male reproductive problems. • Male Malformation:
However, our understanding of basic genitalia –– Hypospadias.
development in general, including hormone-medi- –– Epispadias.
ated genital differentiation, is still very limited. A –– Micropenis.
complete understanding of genetic pathways gov- –– Ambiguous genitalia (genitalia not clearly
erning genital development and masculinization male or female).
and how perturbations of these pathways lead to –– Phimosis.
genital malformations will have important appli- –– Cryptorchidism.
cations to improve global health [7].
The increase in hypospadias incidence along Hypospadias is a condition of mispositioning
with other male dysgenesis in developed coun- of the urethral meatus on the ventral surface of
tries raises the possibility that environmental fac- the penis.
tors, such as fetal exposure to endocrine Epispadias is a rare abnormality (1/30,000
disruptors, may contribute to the development of births) in which the urethral meatus is found on
hypospadias [8]. the dorsum of the penis. Although epispadias
Endocrine disruptors are chemical compounds may occur as an isolated defect, it is associated in
found in the environment, including industrial the extreme form with exstrophy of the bladder
and agricultural compounds, and even natural [11], where the mucosa is exposed to the outside
products found in plants. These compounds, also (Fig. 14.4). Normally the abdominal wall in front
called xenobiotics, can interfere with human of the bladder is formed by primitive streak
physiology by binding to hormone receptors and mesoderm, which migrates around the cloacal
altering gene expression during development. membrane. When this migration does not occur,
Quite a number of xenobiotics structurally rupture of the cloacal membrane extends crani-
resemble estrogen and can bind to the ER and ally, creating exstrophy of the bladder.
affect target gene expression. Exposure to these Micropenis occurs when there is insufficient
compounds has been linked to cancer, the steady androgen stimulation for the growth of the exter-
228 M. Zama et al.
Nowadays, hypospadias is often classified by phogenetic proteins, homeobox genes, and the
the position of the urethral meatus in posterior, Wnt family have been proposed to be implicated
middle, and anterior according to Duckett’s clas- in the normal development of male external gen-
sification. Nearly 70% of hypospadias are either italia [18]. In addition, other risk factors have
glandular or distally located on the penis and are been pointed out such as pregnancy age <20 or
considered mild forms, while the remainder are >35 years, preterm birth, fetal growth restriction,
more severe and complex [16]. primipara, maternal and passive smoking, oral
progesterone, cold or fever during pregnancy,
and exposure to high temperature in early preg-
14.4.2 Etiology nancy [19].
a b c
Normal penis Hypospadias Severe hypospadias
Chordee Deficiency of
pulls penis the foreskin
down
Fig. 14.5 Lateral vision of normal anatomy of urethra of the penis due to the Chordee and deficiency of the fore-
(a), distal hypospadias (b), and severe hypospadias (c) skin (Illustrations by Angelica Pistoia)
with proximal opening of the urethral meatus, curvature
230 M. Zama et al.
Moreover, the middle and posterior forms are penoscrotal junction; perineal from there
those which most frequently occur with chordee down.
(it derives from the Greek word chorda, which • Browne (1936): subcoronal, penile, midshaft,
means “string” or “rope”) and indicates the ven- penoscrotal, scrotal, and perineal varieties.
tral curvature of the penis [23]. • Duckett (1966): anterior (glanular), coronal
Clinical symptoms are variable and depend on and subcoronal, middle (penile), and posterior
the severity of the malformation. In mild hypo- hypospadias (penoscrotal, scrotal, and peri-
spadias with a urethral meatus located on the neal) [26]
glans, a normal urinary flow can be maintained.
In the case of stenotic meatus, weak urinary flow Fortunately, the prevalence of position of the
can occur. Children with proximal hypospadias urethral meatus has different incidence, and the
with penile curvature might not be able to void complex forms represent only 15% of all cases [27].
while standing. A penile curvature in children
can create long-term psychosexual outcomes and
inhibit sexual intercourse in adulthood [24]. Key Point
Special variations of hypospadias are the Prevalence of the position of the urethral
following: meatus:
1. Anterior or distal represents 60–65% of
1. Hypospadias sine hypospadias: ventral curva-
cases.
ture of the penis and a normal position of the
2. Middle represents 20–30% of cases.
meatus with a distorted foreskin [16].
3. Posterior represents 15% of cases.
2. Megameatus intact prepuce (MIP): a coronal
lying meatus adjacent to a nonclosed glans
with a very wide open navicular fossa and a
normal developed circular prepuce [25]. 14.7 Treatment
a b
Apical
Distal
Proximal
Fig. 14.6 (a) Classification of hypospadias based on anatomic location of the urethral meatus; (b) lateral vision of
urethral path in different types of hypospadias (Illustrations by Angelica Pistoia)
most cases, can be performed in a single-stage Each category has, at the OPBG, a surgical
operation that includes meatal advancement and technique of the first choice carried out in a sin-
glanuloplasty (MAGPI), glans approximation gle time:
procedure, and tubularization of the urethral plate
(TIP). Sometimes, for complex form, a two-stage 1. Apical hypospadias uses the technique of slid-
operation is required, like penoscrotal or perineal ing and advancement.
hypospadias [29]. 2. Distal hypospadias uses urethroplasty accord-
Many techniques have been proposed for ing to Mathieu;
hypospadias treatment, but no one is still univer- 3. Proximal hypospadias uses the preputial
sally accepted; at OPBG Hospital, a clinical dis- island flap of Standoli.
tinction is commonly made based on the position
of the ectopic urethral meatus on the ventral face In scrotal and scroto-perineal forms, the
of the penile shaft. This differentiation aims to reconstruction takes place in two or three surgical
have a specific surgical indication for each form. stages: the first stage consists in the pull out of
Therefore, a distinction is made between apical the cavernous bodies according to a modification
hypospadias, from the normal position of the of Jacques van der Meulen’s technique; at the
meatus to the balanic groove; distal hypospadias, second stage, the urethroplasty is performed with
from the balanic groove to the distal third of the the inner layer of the preputial skin; and at the
penis; and proximal hypospadias, which includes third stage, the termino-terminal anastomosis
the other forms where the meatus is located on between the original ectopic meatus and the
the proximal part of the penis, at the penoscrotal reconstructed urethral canal is performed. If con-
junction, at the middle of the scrotum, or at the ditions permit, the second and third stages can be
perineal level (Fig. 14.6). done at the same time.
232 M. Zama et al.
a b c d
Fig. 14.7 Sliding and advancement technique. (a) Incisions along the urethral plate; (b) urethral plate is released and
advanced to the apex; (c) and (d) glanduloplasty and skin closure
Some of the most common and used proce- procedure is completed by glanduloplasty and
dures are shown in the following. preputial skin remodeling (Fig. 14.8).
a b c
d e f
Fig. 14.8 Mathieu urethroplasty. (a) Flap design; (b) flap is raised keeping the vascular pedicle intact (c); (d) flap
sutured in place; (e) glanduloplasty; (f) end of procedure
a b c d e
Fig. 14.9 Standoli preputial island flap. (a) Incision of the preputial flap; (b) flap mobilized with its pedicle; (c) prepa-
ration of the urethral plate; (d) flap being sutured; (e) urethroplasty completed
a b c d e
Fig. 14.10 Standoli preputial island flap. (a) Preputial flap design; (b) dissected flap; (c) flap sutured on the urethral
plate; (d) urethroplasty completed; (e) glanduloplasty and skin closure
234 M. Zama et al.
a b c d
e f g
Fig. 14.11 Standoli double island flap. (a) Penoscrotal of the flap; (e) creating the neo-urethra with the inner
hypospadias; (b) dissection of the whole preputial flap; (c) layer; (f) outer layer of prepuce ready for ventral skin cov-
separation of the outer and inner layer; (d) ventral rotation erage; (g) end of the procedure
In this case, the inner layer will form the ure- an intermediate barrier layer between neourethra
thral canal, while the outer layer will provide and surface skin layer.
adequate skin coverage of the ventral aspect of An infant feeding tube is secured to the glans
the penile shaft (Fig. 14.11). penis for 10–12 days, as drainage of urethral dis-
charge [33] (Fig. 14.12).
a b c d e f
Fig. 14.12 Snodgrass tubularized incised plate (TIP) dissected from preputial and transposed to cover the neo-
steps. (a) and (b) incisions; (c) urethral plate is tubular- urethra; (f) glansplasty and skin closure (Illustrations by
ized from the neomeatus; (d) and (e) dartos pedicle flap Angelica Pistoia)
a b c d
Fig. 14.13 Braka first-stage technique. (a) Incisions around urethral plate and removal of foreskin graft; (b) urethral
plate is excised, removal of urethral plate; (c) glans incision; (d) graft affixing (Illustrations by Angelica Pistoia)
e f g h
Fig. 14.14 Braka second-stage technique. (e) penis is degloved; (f) neourethral plate is tubularised around catheter; (g)
dartos fascia flap is placed over the suture; (h) glansplasty and skin closure (Illustrations by Angelica Pistoia)
32. Snodgrass WT, Bush N, Cost N. Tubularized incised ment enabling evaluation by surgeons and patient
plate hypospadias repair for distal hypospadias. J self-assessment after hypospadias repair. J Urol.
Pediatr Urol. 2010;6(4):408–13. 2013;189:189–93.
33. Hombalkar N, Gurav P, Dhandore D, Parmar 38. Holland AJ, Smith GH, Ross FI, Cass DT. HOSE: an
R. SNODGRASS procedure - a versatile technique objective scoring system for evaluating the results of
for various types of hypospadias repair. J Krishna Inst hypospadias surgery. BJU Int. 2001;88:255–8.
Med Sci Univ. 2013;2:116–22. 39. Varni JW, Seid M, Rode CA. The PedsQL: mea-
34. Altarac S, Papeš D, Bracka A. Two-stage hypospadias surement model for the pediatric quality of life
repair with inner preputial layer Wolfe graft (Aivar inventory. Med Care. 1999;37:126–39. https://doi.
Bracka repair). BJU Int. 2012;110(3):460–73. org/10.1097/00005650-199902000-00003.
35. Rynja SP, de Jong TP, Bosch JL, de Kort 40. Van der Toorn F, et al. Introducing the HOPE (hypo-
LM. Functional, cosmetic and psychosexual results in spadias objective penile evaluation) score: a validation
adult men who underwent hypospadias correction in study of an objective scoring system for evaluat-
childhood. J Pediatr Urol. 2011;7(5):504–15. https:// ing cosmetic appearance in hypospadias patients. J
doi.org/10.1016/j.jpurol.2011.02.008. Epub 2011 Pediatr Urol. 2013;9:1006–16.
Mar 22 41. Golomb D, Sivan B, Livne PM, Nevo A, Ben-Meir
36. Deibert CM, Hensle TW. The psychosexual aspects D. Long-term results of ventral penile curvature repair
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2011;9:279–82. 42. Tourchi A, Hoebeke P. Long-term outcome of male
37. Weber DM, Landolt MA, Gobet R, Kalisch M, genital reconstruction in childhood. J Pediatr Urol.
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Part lll
Plastic Surgery for Trauma
Wounds
15
Giovanni Papa, Stefano Bottosso, Vittorio Ramella,
and Zoran Marij Arnež
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 241
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_15
242 G. Papa et al.
It is important to remember that the deeper ana- fever, and malaise. Infections usually involve soft
tomical layers can slide underneath during trauma tissues, generating cellulitis or a phlegmon with
and then return to their original position, leading to abscess formation and lymphadenopathy. In bites
an underestimation of the true depth of the wound of the hands are common tenosynovitis and joint
at a first evaluation. Bites that may appear harmless empyema. In some cases, the local infection can
on the surface may instead involve deep tissue and evolve into a systemic infection.
have important clinical relevance. Surgical treatment of bite wounds consists in
In general, 10–20% of bite wounds become debridement of necrotic tissue, wound irrigation,
infected, including 30–50% of cat bites, 5–25% and wound closure. Surgical debridement is
of dog bites, and 20–25% of human bites [6]. superior to irrigation for the removal of devital-
Also, 30–60% of infections in bites are mixed ized tissue. There is a clinical consensus that
infections with aerobic and anaerobic germs, wounds in the face should be closed primarily
coming from the oral flora of the animal that has [8]. For bite wounds on the limbs, it is generally
bitten or, more rarely, from the skin flora of the accepted that can be closed 12 h after trauma or
victim or from the environment [7]. Along with longer. Primary closure is contraindicated for
Staphylococcus ssp. (including MRSA) and puncture wounds, bite wounds on the hands, and
Streptococcus ssp. (including pyogenes), the human bites (except on the face).
commonly isolated pathogens reportedly include Meta-analyses do not recommend prophy-
Pasteurella spp. (, Pasteurella canis, Pasteurella laxis with antibiotics in the Cochrane Database
dagmatis), Capnocytophaga canimorsus, anaer- [9]. Nevertheless, most physicians prescribe
obes (Fusoacterium spp., Prevotella spp., 3–5 days of antibiotic treatment in deep bite
Bacteroides spp., Porphyromonas spp.), and oth- wounds and in wounds in critical areas of the
ers [6] (Table 15.1). Clinical signs of infection body (hands, feet, areas near joints, face, geni-
are redness, swelling, purulent secretion, pain, tals) or in patients at high risk of infection.
Targeted antibiotic treatment is given for mani-
fest bacterial infections [7].
Key Point
Bite wounds are at high risk of infection
and are often underestimated. A meticulous
surgical debridement is important.
Prophylactic antibiotics are indicated if
there is a high risk of infection. Wounds in
the face should be closed primarily.
Fig. 15.4 Dog bite in a young woman nose and upper lip
15.2.1.2 Snakebites
It is a rare condition in the developed countries. cutaneous dystrophy (Fig. 15.5). The
The most frequent venomous snakes indigenous majority of these wounds occur in health-
to the United States are cotralids and elapids. No care settings. Severity may vary by depth,
evidence-based recommendations exist. but they never extend through the subcuta-
In the case of snakebite, the first thing to do is neous layer.
immobilization, identification of the snake, and The treatment of skin tears involves an
assessment of envenomation. If there is enven- accurate cleaning of the wound bed and
omation or mild–moderate envenomation, only flap repositioning (with a damp gauze or
observation and supportive therapy are indicated. with a wet finger). Due to skin fragility,
In the case of major envenomation, it is appropri- stitches should be avoided, and nonadher-
ate to perform fluid resuscitation, laboratory ent dressings are indicated in order to
evaluation, and correction of coagulopathy and keep the skin in position, balance the
administer polyvalent antivenin. In this case, the wound exudate, and allow an atraumatic
evaluation of the compartment syndrome and the removal [10].
possible execution of fasciotomies are essential.
–– Noble anatomical structures are involved In the management of limb trauma, angiogra-
(depends on depth and localization of the phy or angio-CT are often indicated for the
wound). assessment of the vascular status, both for diag-
–– There are signs of ischemia or patients factors nosis and preoperative planning of reconstructive
that increase the risk of ischemia of the trau- procedure, along with Doppler or color Doppler
matized area. ultrasonography.
–– It is at high risk of infection or a patient’s fac-
tor that increases the risk of infection.
15.3.5 Diagnostic Tests
ficient. Since traumatic wounds are contaminated four “Cs”: color, contraction, consistency, and
by definition, it is important to use detergents capacity of bleed [18].
with surfactant action. They act by breaking the Debridement to bleeding tissue serves as the
hydrophobic or electrostatic forces that guide the endpoint for most tissues. Still, specialized tis-
initial stages of adhesion of bacteria to the sur- sue, such as cartilage, tendon, and irradiated
face [15]. wounds, often requires experienced judgment
Wound debridement is the most important and careful consideration. Multiple operative
procedure of wound treatment. Inadequate wound debridements may be necessary to archive
debridement before closure brings to postopera- wound stability depending on the necrotic and
tive infectious complications. Operative wound infection bioburden. However, multiple serial
debridement must be systematic and thorough, debridement has been shown to be associated
working simultaneously with wound exploration. with worse outcomes [19].
It is important to determine tissue viability The standard of surgical debridement is sharp
through examination of the color, temperature, debridement. It is classically performed with the
and presence of bleeding. Debridement consists scalpel blade or scissors. The tissue is removed in
in the removal of devitalized, infected, or necrotic sections until bleeding tissue is reached. Often,
tissue from the wound [16]. At the end of the curettes can be used to perform a scraping action
debridement, each cavity must have been on the tissues like granulation tissue, bone, or
explored and the surrounding anatomy known. At small cavity. Another useful tool for surgical
the heart of the debridement is the surgeon’s debridement is hydrocision [20, 21]. This tool
knowledge of the anatomy [5]. Small islands or allows to simultaneously cut, remove, and rinse
pedicles of tissue are frequently devascularized tissue with a water jet through a high-pressure
and should be removed. Inorganic material left in opening, resulting in an ideal for soft tissue
the dermis or superficial subcutaneous tissue can debridement. Studies done on wound biofilms in
result in tattooing and should be removed when- a polymicrobial porcin model have shown an
ever possible [12]. almost 1000-fold reduction in bacterial colonies
using Versajet® (Smith-Nephew, Hull, UK) and
significant reductions in inflammatory neutrophil
Key Point markers [22]. Other studies demonstrate that
Wound debridement is the most important Versajet may be equally if not more effective than
procedure of wound treatment. Inadequate conventional surgical debridement by causing
debridement before closure brings to post- less damage to viable tissue and appear to be
operative infectious complications. It con- cost-effective by minimizing surgical duration
sists in the removal of devitalized, infected, and length of hospital admission [23].
or necrotic tissue from the wound to allow Another useful instrument for debridement is
the remaining tissues’ primary healing. the ultrasound system. Low-frequency, low-dose
ultrasound has been found to break down dead
tissue. These methods are painless and reduce
Skin is relatively resilient but is vulnerable to bacterial burden [24] but will require several
torsion and avulsion injuries, which lead to treatments [25].
degloving and disruption of the septocutaneous In selected cases, a conservative sharp wound
and musculocutaneous perforating vessels [17]. debridement can be performed. It consists in the
In the case of extensive flap lacerations, all non- removal of loose and devascularized tissues
viable skin must be excised. Care must be taken above the level of viable tissue. In this type of
to the viability of the subcutaneous fat. The area debridement, only clearly devitalized tissues are
of fat necrosis is often more extensive than that of removed, retaining surrounding tissues that are
the overlying skin. Devitalized muscle may be traumatized but have healing potential. In this
difficult to assess, and it is useful to look for the case, a second look is mandatory to evaluate the
15 Wounds 249
tissues left in place [26]. It is important, after sur- cal antiseptic dressings may diminish topical
gery, to indicate the type of debridement microbe load and decrease the risk for potential
performed. infection [30].
In wounds that remain open, due to the Between staged debridements, various types
patient’s general situation, to the impossibility of dressings are available. Negative pressure
of performing surgical interventions or the therapy and antimicrobial dressings play a major
wound’s local characteristics, it may be neces- role as a bridge to reconstruction, creating heal-
sary to continuously manage the wound bed by ing environments and improving efficacy and
maintenance debridement to remove the biofilm comfort for the patient. Negative-pressure wound
constantly [27]. therapy (NPWT) has revolutionized wound care
since it was popularized by Morykwas et al. and
Argenta and Morykwas in 1997 [31, 32]. These
Key Point articles demonstrated an increased rate of granu-
The surgeon should know the type of lation tissue formation, decreased edema, and
debridement performed: in the case of a increased localized blood flow in the area treated.
radical one, he/she can close the wound After surgical debridement, the use of NPWT
immediately; in the case of a conservative allows delaying the reconstruction to 7 days after
one, he/she should perform a second look, injury, keeping the wound in its acute phase, as it
after some time, in order to evaluate the maintains the wound bed isolated and clean. It
trend of the tissues. manages wound fluid exudate, minimizing dress-
ing changes and exposure to bacteria, inflamma-
tory cytokines, and matrix metalloproteinases
During surgical debridement, a bacterial [33]. Nevertheless, NPWT is not a substitute for
quantification of wound could be necessary, appropriate medical and surgical care, nor is it a
depending on wound’s contamination and timing debridement modality by itself. Contraindications
of the injury. Acute traumatic wounds can be con- to its use are exposed vessels, malignancy,
sidered contaminated wounds or dirty. Antibiotic necrotic tissue, untreated osteomyelitis, or non-
prophylaxis may be beneficial in those wounds enteric and unexplored fistulas [34]. The use of
because of the high risk of infection. The deci- negative-pressure wound therapy with instillation
sion to use antibiotic prophylaxis depends on an is appropriate for patients with substantial comor-
accurate evaluation of the patient’s comorbidities bidities that impair wound healing or response to
and risk of infections. It should be associated the infection of those who have a complex wound,
with postoperative dressing strategies, antiseptic like wound complicated with invasive infection
wound dressing, and antiseptic agents. Superficial or extensive biofilm, diabetic foot wound infec-
swab specimens collected at the time of injury tions, and severe or contaminated traumatic
are inappropriate and without clinical value for wounds [35]. Studies demonstrate that instilla-
therapy. It can be useful for knowing the host tion of normal saline can achieve comparable
microbiome. In the case of signs and symptoms outcomes to other types of solution [35].
of infection, the etiological diagnosis is crucial.
After initial debridement and cleansing of super-
ficial lesions, collecting a deep tissue is the most Key Point
appropriate method for identifying the etiological NPWT, after debridement, plays a major
pathogen [28]. role as a bridge to reconstruction, increas-
The Centers for Disease Control and ing formation of granulation tissue,
Prevention recommended against the use of topi- decreasing edema, and increasing localized
cal antibiotic agents for prevention of SSIs blood flow.
(except silver sulfadiazine [29]). In contrast, topi-
250 G. Papa et al.
Until new evidence, wound irrigation provides Table 15.2 Advantages and disadvantages of the differ-
adequate wound preparation. Irrigation of the ent technique of wound closure
laceration reduces the likelihood of infection. Technique Advantages Disadvantages
The irrigation’s objective is to physically remove Secondary • Simple •E xtended time of
intention • Avoidance of a period to healing
bacteria and foreign material present in the
closed wound • Dressing changes
wound that can serve as a nidus for bacterial con- infection • Suboptimal scar
tamination. There is little evidence to support the Primary • Simple •P otential wound
use of one lavage fluid over another. A large ran- closure •B est healing infection
domized controlled trial found no significant dif- potential •P otential need of
advanced surgical
ference in reoperation rates between castile soap technique
and normal saline for wound irrigation in open Skin graft • Simple and quick • N ecessity of
fractures. In contrast, it found an increased over- • No need creation meticulous wound
all infection rate in the castile soap group [36]. of flap bed preparation
•P oor esthetic
While the type of fluid is not important, the irri- outcome
gation technique may impact wound healing. • Less durable result
Some studies report that, despite the removal of Local flaps • Their own blood • M ore complex
some contaminants and debris by conventional supply operation
• Similar texture •S mall zone of
low-pressure irrigation with gravity flow and
• Durability injury needed
bulb syringe methods, only high-pressure pulsa- Free tissue •F reedom in •M ore complex
tile jet irrigation lowered the numbers of E. coli transfer reconstruction for operation
significantly [37]. However, conflicting studies complex and •M orbidity of the
show that high-pressure pulsatile lavage pene- specialized area donor site
trates and disrupts soft tissue to a deeper level
than low-pressure lavage, causing considerable optimal wound bed preparation. The disadvan-
gross and microscopic tissue disruption [38]. The tages include the extended time period to healing,
FLOW trial demonstrates no statistically signifi- dressing changes, and often a suboptimal scar.
cant difference in reoperation rates between high-
pressure pulsatile lavage and low-pressure 15.4.2.2 Primary Closure
pulsatile lavage, establishing very low pressure Primary closure by direct suture is the most reli-
as an acceptable, low-cost alternative in the irri- able technique with the lowest rate of dehiscence.
gation of open fractures [39]. Sutures can efficiently repair even more complex
laceration. The choice of technique repair must
not be arbitrary but needs to be based on wound
15.4.2 Wound Closure characteristics and kind of patient:
A useful tool to plan the wound closure is the • Simple interrupted sutures are excellent for
reconstructive ladder. It is a guideline to recon- wound edge approximation. Every suture is
struction, and each case should be looked at on an placed and tied individually. There is an excel-
individual basis, considering the patient’s charac- lent control over the level of wound eversion,
teristics and the wound’s anatomy in order to and interrupted sutures give a good result in
choose the best option for closure (Table 15.2). curved and nonlinear wounds. If infection
occurs, only a few sutures need to be removed
in order to drain subcutaneous collection.
15.4.2.1 Secondary Intention • Intradermal suture can be used in the event
After adequate debridement, a wound can close that the wound is made linear by debridement
spontaneously. It is the first and most straightfor- as if it were a cut wound.
ward technique. It can be used in superficial • The mattress sutures are efficient in reducing
wounds or according to the patient’s general skin margin tensions and helpful in creating
clinical condition, with an adequate dressing and some sort of eversion, but they can cause
15 Wounds 251
impaired skin perfusion. This technique the multifilament suture is the better knot
increases the interphase or contact between strength. Monofilament sutures pose lower resis-
the raw surface areas of two opposing wound tance on tissue passage and tend to snug down
sides. more readily. When used on the subcutaneous or
• The figure-of-eight suture can simultaneously intradermal level, multifilament sutures tend to
close two levels of depth, reduce rounded be extruded in the form of a suture sinus or small
defects, and fix the nail to its bed after localized abscess, compared with a monofila-
damage. ment, which behaves in a cleaner, less reactive
• The running sutures are easy and fast to do. manner.
They can offer a very good hemostasis, espe- Sutures can be absorbable or nonabsorbable.
cially in scalp wounds. This technique is com- The absorbable ones are useful for deep layers’
monly used when the wound is actively sutures or in the pediatric population that can be
bleeding and saving time is critical. The disad- less compliant during stitch removal. In these
vantage is that suture breaks can cause wound cases, it is important to consider the reabsorption
gaps to occur. If the suture material breaks in time of the filament that must be sufficient to
a running suture, the whole wound will break keep the wound closed even during movement
down. For this reason, it is important to secure and under tension. Nonabsorbable sutures are
the knots on the two sides and consider adding instead appreciated for their nonresponsiveness
a couple of interrupted sutures in addition. to surrounding tissue and for maintaining their
tensile strength during time.
In most traumatic wounds, subcutaneous or
subcuticular sutures are mandatory to close dead
spaces and approximate wound edges. They are Tips and Tricks
performed with absorbable sutures and with bur- It is important to minimize scar tissue for-
ied knots. Subcutaneous sutures should be placed, mation, ensuring that wound edges are not
preferably taking a bite of fascia to add strength inverted during closure. The inversion will
and not cause unnecessary liponecrosis. delay and/or compromise the healing pro-
Subcuticular sutures should be anchored to the cess and leave an unsightly scar. It is appro-
deep portion of the dermis. priate to suture wounds with everted, or
The wire size is expressed using the USP slightly lifted outward, edges.
(United States Pharmacopeia) system. It centers Tension is the other factor that does not
around the “0” suture. Suture sizes increase from favor good healing. In order to obtain
size 0 to size 1, 2, and upward and decrease in tension-free approximation of the margins,
size from 0 to size 2–0, 3–0, and downward. The it is necessary to detach the surrounding
use of different wire sizes depends on wound tissues. The detachment must occur in the
dimension and tension. The smallest diameter of correct anatomical plane that maintains
the suture that will accomplish the purpose skin vascularization to achieve the best
should be chosen to minimize the tissue trauma wound edge approximation, avoiding dead
with each passage of the needle and the amount spaces. This is mandatory in the case of
of foreign material left inside. It is essential not to loss of skin substance caused by trauma or
place large sutures near the most superficial lay- by subsequent surgical debridement.
ers of the dermis.
Whether a suture has a single or multiple
strand composition is an important consideration. The disadvantages of sutures are local anes-
The use of multifilament is not recommended in thesia administration, time-consuming patient
contaminated or infected wounds because it can positioning, and an inflammatory tissue reaction.
increase the infection rate as the microorganisms If left in place for a long time, it can cause perma-
can nestle between the fibers. The advantage of nent marks on the scar’s sides.
252 G. Papa et al.
Recently, tissue adhesives have been widely of flaps. The disadvantages are the necessity of
used due to their easy application. They are espe- meticulous wound bed preparation, poor esthetic
cially used in wounds without tension with cos- outcome, and less durable result compared with
metic results comparable to sutures. They are not flaps.
generally indicated in complex laceration that Local tissue rearrangement consists in the cre-
cannot be approximated manually. In these cases, ation of small geometric random flaps or larger
they can be used only if adequate deep sutures are flaps based on axial circulation. The advantages
already positioned and the margins are well of local flaps are their own blood supply, texture
approached. It is not indicated to use this tech- similar to the surrounding tissues, and durability.
nique in tension areas or subjected to the repeated Disadvantages include the need for a more com-
movement (as articular areas or hand). plex operation and a small zone of injury.
Staples are a quick closing technique and help
repair wounds of the scalp. They are associated 15.4.2.4 Free Tissue Transfer
with less foreign body-like reactions and infec- Free flap transfer is the most complex technique
tion. Staples do not provide optimal margin for acute wound closure. This method has all of
approximations like sutures. Still, they are con- the advantages of the local flap with the benefit of
sidered a good alternative in an emergency when transferring the tissue anywhere on the body. The
we do not have enough time, mostly in hidden advantages are its freedom to reconstruct com-
areas. Removing staples is more complex than plex and specialized areas where local flaps are
sutures, and the maneuver is more painful. not available. Free flap success rates are well over
Adhesive tapes can be applied quickly and 95% at microsurgical centers. Disadvantages are
easily, without any discomfort for the patient. the need for a more complex operation and the
They are also associated with minimal tissue morbidity of the donor site.
reactivity. They can be left in place for a long
period of time. They have little tensile strength,
Pearls and Pitfalls
and so they are not able to approach margins cor-
As the simplest solution is not always the
rectly in tension areas. Moreover, it can cause
best, the “reconstruction ladder” was modi-
blister formation due to the presence of shearing
fied in “reconstructive elevator.” the most
forces on the epidermis. Tapes are very useful,
surgical demanding technique can be the
especially after sutures removal, to reduce wound
first option if indicated. The reconstructive
tension. They cannot be used in haired areas, and
elevator encompasses the creativity needed
also the taped area should not be wet as it would
to treat the wound in the best possible way
lead to dislocation of the tapes.
[40] according to the local and general clin-
ical situation of the patient (personalized
15.4.2.3 kin Grafting and Local
S
treatment on the patient).
Flaps
When a soft tissue defect is too large to be closed
primarily or when the primary closure results in
unwanted tension and tissue distortion, local skin 15.4.3 Wound Dressing
flap or skin graft may be used.
In a skin graft, an underlying bed to supply the The function of a wound dressing is to provide a
nutrients and ultimate blood supply is required. good environment for healing (Fig. 15.7).
Meticulous wound bed preparation, hemostasis, In the case of acute wound treated by pri-
and appropriate dressing to protect the graft are mary intention, a simple dressing is commonly
mandatory. Skin grafting is a simple and quick used to cover the wound. The purpose of the
technique for wound closure without the creation dressing is to protect the suture from external
15 Wounds 253
site infection in wounds healing by primary intention. 36. FLOW Investigators, Petrisor B, Sun X, Bhandari
Cochrane Database Syst Rev. 2016;11(11). M, Guyatt G, Jeray KJ, et al. Fluid lavage of open
30. Berrios-Torres SI, Umscheid CA, Bratzler DW, wounds (FLOW): a multicenter, blinded, facto-
Leas B, Stone EC, Kelz RR, et al. Centers for rial pilot trial comparing alternative irrigating solu-
Disease Control and Prevention guideline for the tions and pressures in patients with open fractures. J
prevention of surgical site infection. JAMA Surg. Trauma. 2011;71(3):596–606.
2017;152(8):784–91. 37. Brown LL, Shelton HT, Bornside GH, Cohn I Jr.
31. Morykwas MJ, Argenta LC, Shelton-Brown EI, Evaluation of wound irrigation by pulsatile jet and
McGuirt W. Vacuum-assisted closure: a new method conventional methods. Ann Surg. 1978;187(2):170–3.
for wound controland treatment. Animal studies and 38. Boyd JI 3rd, Wongworawat MD. High-pressure pul-
basic foundation. Ann Plast Surg. 1997;38:553–62. satile lavage causes soft tissue damage. Clin Orthop
32. Argenta LC, Morykwas MJ. Vacuum-assisted clo- Relat Res. 2004;427:13–7.
sure: a new method for wound control and treatment. 39. Investigators FLOW, Bhandari M, Jeray KJ,
Clin Exp Ann Plast Surg. 1997;38:563–77. Petrisor BA, Devereaux PJ, Heels-Ansdell D, et al.
33. Mendonca DA, Papini R, Price PE. Negative-pressure A trial of wound irrigation in the initial manage-
wound therapy: a snapshot of the evidence. Int Wound ment of open fracture wounds. N Engl J Med.
J. 2006;3(4):261–71. 2015;373(27):2629–41.
34. Desai KK, Hahn E, Pulikkottil B, Lee E. Negative 40. Gottlieb LJ, Krieger LM. From the reconstructive lad-
pressure qound therapy: an algorithm. Clin Plast Surg. der to the reconstructive elevator. Plast Reconstr Surg.
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35. Kim PJ, Attinger CE, Crist BD, Gabriel A, Galiano R, 41. Foster L, Moore P. Acute surgical wound care. 3: fit-
Gupta S, et al. Negative pressure wound therapy with ting the dressing to the wound. Br J Nurs. 1999;8(4).
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Upper Limb Trauma
16
Bruno Battiston, Maddalena Bertolini,
Paolo Titolo, Francesco Giacalone, Giulia Colzani,
and Davide Ciclamini
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 257
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_16
258 B. Battiston et al.
ning treatment. However, in lesions at joint level, [5]. Actually, plating is the preferred method of
the articular surface alterations should be studied treatment, but also Ex Fix is often a good
by means of CT scan for a good understanding solution.
and a correct treatment plan. Articular fractures Scaphoid fractures are really common which
need open reduction and synthesis to restore the can lead to severe secondary problems if not rec-
best joint anatomy and following function. More ognized. Then, careful clinical and radiographi-
and more in articular trauma we should consider cal evaluation should be done in all wrist sprains.
not only the bony elements but also the ligament Treatment again may be conservative or surgical
structures, often surgically reconstructing them (with screws) depending on fracture site (proxi-
to avoid secondary instabilities. No EBM exists mal ones are the worst), displacement and
on the superiority of one special device to treat patient’s needs (conservative treatment needs at
upper limb fractures. The use of plates, nails, least 45–60 days of immobilization).
K-wires or external fixators, if correctly man- For most fractures of metacarpals and phalan-
aged, leads to similar results. The choice is gen- ges, closed manipulation, proper splinting and
erally made on the type of fracture (transverse, protected motion will produce good functional
oblique, spiral, comminuted) and the patient’s results. Criteria for surgery are degree of dis-
needs (age, profession, etc.). Anyway, we need placement (> than 15–30° of angulation), rota-
stable synthesis allowing early mobilization, pos- tional deformities, unstable or open fractures,
sibly not interfering with soft tissues. Then, Ex multiple fractures and articular displaced frac-
Fix is mainly used in open, contaminated lesions tures. Even at this level, the surgical technique
or for a “damage control” before the final treat- will use K-wires, simple screws or plates accord-
ment (in politrauma, etc.) [4]. Simple K-wires are ing to the fracture type but with the aim of maxi-
less and less used, changed by more stable mod- mal stability for an early mobilization in order to
ern synthesis devices. avoid tendon stuck and stiffness, frequent com-
The wrist and hand are specialized structures plications at this level.
in the upper limb with special needs. The good
functional recovery at this level needs good anat-
omy restoration and early motion, even more 16.2.2 Tendons
than in other sites. Particularly at the metacarpal
and finger level, attention should be given to sec- In recent years, a significant amount of studies in
ondary deformities, especially rotational prob- the field of tendon injury in the hand has contrib-
lems. A closed or open approach should prevent uted to advances in both surgical techniques and
malrotation, checking the plane of the fingernails postoperative motion protocols. The introduction
with MP flexion, otherwise leading to finger of early motion has improved tendon healing,
overlapping and relevant dysfunction. reduced complications and enhanced final out-
At the wrist level, the most common lesions comes [6]. Whatever the type, or level, of flexor
are distal radius and scaphoid fractures. Distal or extensor injury, the ultimate goal is to perform
radius extra-articular or partially displaced artic- a strong suture and a gliding tendon, protect the
ular factures in the aged patient are generally repair, modify peritendinous adhesions, increase
reduced and managed conservatively. On the tendon excursion and preserve joint motion.
contrary, articular involvement, especially in Flexor tendons of the hand are divided into
young patients, needs surgical repair particularly five zones (Fig.16.1).
if there is shortening >2 mm and an articular step Bunnell, in 1918, coined the term “no man’s
>1–2 mm. The predictors of fracture instability, land” to describe zone 2 in the hand, because at
then needing surgery, are multifragmentary frac- that time it was felt that no man should attempt
tures, dorsal comminution, relevant displacement repair within this zone. While this belief fell, ten-
and ulnar and/or radio-ulnar joint involvement don repair in this zone remains challenging for
16 Upper Limb Trauma 261
a b
Fig. 16.9 (a) In proximal nerve lesions, an epi-perineurial Distally, a perineurial suture is preferred to better match
suture is sufficient to face not yet well-defined groups of well-defined motor or sensory nerve components
fascicles respecting a topographical distribution. (b)
reasons, sometimes, small defects require more Thumb apical defects are often treated with a
complex flaps than large well-vascularized soft volar advanced flap (Moberg): radial and ulnar
tissue lesions. midaxial incision defines a flap that is elevated in
Extensive literature is available concerning the plane above the flexor tendon sheath.
the variety of local and regional flaps that may be Reconstructions of larger dorsal and volar api-
used for coverage of upper limb soft tissue cal problems by cross finger flaps, utilizing sub-
defects. The continous endeavour toward optimi- cutaneous tissue and skin of the adjacent finger
zation of reconstructive techniques, both in terms with donor and recipient site remaining attached
of minimization of donor site defects or morbid- for at least 2–3 weeks before being divided and
ity and in terms of refinements of the recon- insetted, are less and less performed and changed
structed site and function brought to the gradual by homodigital and heterodigital flaps. These are
substitution of simple random flaps or axial flaps usually axial flaps that are elevated in an antero-
based on constant vessels (i.e. LateralArmFlap, grade or retrograde fashion, based on the digital
Dorsal Interosseous Flap, etc) or even sacrificing arteries or its branches.
one main artery (i.e. radial or ulnar forearm flap) These latter are also used for more proximal
with flaps based on perforator vessels as described digital reconstructions, where another source of
by Koshima on 1989 [13]. flaps is the dorsum of the hand using the dorsal
The hand represents a special issue. Until the metacarpal network (anterograde or reverse dor-
1990s, soft tissue reconstruction in the hand was sal metacarpal flaps).
limited to a small variety of flaps. After the ana- The number of digital flaps described in litera-
tomical studies describing the interconnections ture is so large that we send the reader to special-
between the palmar arterial system and its perfo- ized book chapters.
rating vessels into the vascular network of the The regional tissue used for coverage of the hand
dorsum of the hand, many new flaps even based are distally based fascial or fasciocutaneous flaps
on small perforating vessels have been that rely on flow from the radial or ulnar artery.
developed. The reverse radial and ulnar forearm flap, for
In contrast to traditional distant pedicle flaps, instance, are based on the blood supply coming
intrinsic flaps (raised within the territory of the from the communication with the other main
hand and based on intrinsic vessels) allow defect artery through the intact palmar arch.
closure and early active mobilization. Intrinsic The posterior interosseous artery flap is
flaps, as every flap, are generally classified another example of regional flap used to cover
according to recipient and donor location (homo- palmar or dorsal hand wounds and is based on the
or heterodigital flap, dorsal metacarpal, etc.) and watershed communications of the anterior inter-
their vascularization: random pattern flap, axial osseous artery on the volar wrist with the poste-
pattern flap with proximal or distal inflow rior interosseous artery in the fifth dorsal
(anterograde-retrograde flap) or local perforator compartment of the dorsal wrist.
flaps. Nevertheless, there are some areas where the
Soft tissue reconstruction of the hand could be use of free flaps can be made irreplaceable for the
divided up into three main areas: fingertips, digits limited availability of local flaps or the complex-
and hand. ity of the lesion in terms of dimensions and
The fingertip is an area where local flaps are involved structures. If the most commonly used
commonly used for reconstruction of traumatic free flaps in the upper limb were generally the
skin loss. parascapular, latissimus dorsi, serratus anterior,
One of the most performed flaps for small api- gracilis and flaps from the foot, representing the
cal oblique or transverse defects is the volar VY conventional workhorses of reconstruction, in the
advancement flap (Tranquilli-Leali flap), but last few years, the flaps based on perforator ves-
occasionally a laterally based V–Y advancement sels represent one of the major recent technical
(Kutler flap) may be used. advancements decreasing donor site morbidity.
266 B. Battiston et al.
In the hand, it’s important to distinguish the which may produce extensive tissue lesions that
reconstruction of the dorsum or of the palm. increase complications and lead to poor func-
The back of the hand is covered with hairy, tional results. In mangled upper limbs, the key
thin and very mobile skin allowing tendon glid- point for decision-making is a careful assessment
ing and finger and wrist movements. The charac- of the involved structures. Based on this evalua-
teristics of the ideal flap should be thinness, tion, the surgeon will decide on amputation
elasticity and a good gliding surface. (extremely crushed segments with extensive tis-
Among the free flaps, the anterolateral thigh sue loss) or reconstruction. In the latter case, a
flap (ALT) and the superficial circumflex iliac plan is to be done deciding for an early total care
artery perforator flap (SCIP) are very good (debridement, bone definitive synthesis and con-
options: they are foldable, offer a good gliding temporary soft tissues repair) or a damage con-
surface for tendons (adipofascial flaps) and have trol (good debridement and temporary
ideal donor sites. Both flaps are almost always stabilization, generally with external fixation)
too thick to offer a valid functional and aesthetic followed by an early or delayed reconstruction.
result, but many authors described how much The decision-making process may utilize indexes
they can be thinned after harvesting. The dorsalis as the MESS system which help in deciding if
pedis offers an optimal reconstruction from an amputate or not but have limitations in under-
aesthetic and functional point of view (thin and standing the possible functional recovery of the
foldable skin, tendons can be included) but has a traumatized limb [2]. In mangled upper limbs,
relevant donor site morbidity. the simultaneous treatment of the fractures and
The palm of the hand is an extremely special- the associated soft-tissue injuries is spreading so
ized structure as the skin is glabrous, thick, very much to create a new “orthoplastic approach” for
horned but at the same time elastic to allow pro- extremity trauma [3]. Microsurgical flaps, espe-
tection and good grip. The ideal flap should be cially in a composite setting, may solve in one-
formed by glabrous, resistant skin, well adherent stage severe combined tissue loss, needing
to the underlying planes and sensitive. The free contemporary orthopaedic and plastic compe-
medial plantar foot flap, based on branches of the tence. The reconstruction of combined bone and
medial plantar artery, faithfully reproduces all soft tissues defects, even with traditional tech-
these characteristics when simple thick skin niques, is more than a simple decision on the sys-
grafts or local flaps are not sufficient. tem to be adopted: it is mainly a question of
When local flaps are not possible, the thumb timing and then of strategy. If the lesion is clean
and the long fingers have the ideal pick-up site or sufficiently debrided, we may consider an “all-
for the reconstruction from the toes as the anat- in-one” reconstruction by means of bone grafts,
omy and sensibility matches as no other donor osteosynthesis and coverage flaps (fix and flap).
site may do. The indications for reconstruction of If the general conditions of the patient are critical
the thumb are different depending on the level of and/or the lesion is highly contaminated, a recon-
injury. Injuries involving the fingertip can be struction in two or more stages is suggested. An
repaired with a free toe pulp flap, while more early reconstruction 3 to 5–6 days later is gener-
proximal lesions, also involving the nail, may be ally suggested if allowed by patient’s general
reconstructed with the Morrison flap (wrap- conditions. The main goal is reconstruction of the
around and variances). coverage with a flap. The underlying structures
(tendons, bone, etc.) may be repaired at the same
time, even with a composite free flap, or second-
16.2.5 M
angled Upper Limb arily with the same techniques already described
and Amputations in the previous paragraphs.
If trauma caused sub-amputation with devas-
Nowadays, clear-cut injuries are dropping off and cularization or a complete amputation at upper
are being substituted with high-energy traumas limb level, a revascularization/replantation of the
16 Upper Limb Trauma 267
segment is to be considered. Replantation of an injuries are the priority. Replantation can be con-
amputation, the dream of all surgeons in the past, sidered after achieving stable general conditions.
is no longer a technical problem. However, what Smoke habit is no more an absolute
we really want from a replant is not just survival contraindication.
but mainly function. The important role of emer- Revascularization time must not exceed 6 h of
gency organization in this type of surgery is to be warm and 12 h of cold ischemia if segments con-
emphasized as the preservation of the amputated tain large muscular masses and 12 h of warm and
parts. Then, indications for replantation will fol- 24 h of cold ischemia for digits. This rule not
low careful and objective patient selection, with a only guarantees limb survival but also avoids
careful examination of the general conditions and severe postoperative complications such as car-
of the amputated part. The main general criteria diac or renal failure. The correct preservation of
for the decision are patient’s age and general con- the amputated part has a key role in a successful
ditions, ischemia time and level, type and extent replantation.
of tissue damage [14]. As for the level of lesion, we do believe that
People over the age of 60 generally have even in very proximal amputations, we may get
greater number of complications and worst an often elementary but useful limb [14]
results. Associated multiple lesions (head trauma, (Fig. 16.10).
etc.) and poor general conditions are generally Double-level lesions are generally contraindi-
considered a contraindication as life-threatening cations, even though in some cases, a replanta-
a b
c d
Fig. 16.10 (a and b) Amputation by avulsion at arm level mus dorsi transfer for biceps reconstruction. Reinnervation
in a motorcycle accident. (c and d) Clinical result 2 years even of the hand allowed the patient to use it in grasping
after the replantation and a second intervention of latissi- and to get back to normal daily life
268 B. Battiston et al.
a b c
Fig. 16.11 (a) Thumb amputations at P1 level by circular saw. (b and c) Clinical and radiographical result at 6 months
Early recovery of motion is the main goal in 3. Lerman OZ, Kovach SJ, Levin LS. The respective
roles of plastic and orthopedic surgery in limb sal-
rehabilitation depending on the stability of vage. Plast Reconstr Surg. 2011;127:215S–27S.
osteosynthesis and on the quality of microvas- 4. Guerado E, Bertrand ML, Cano JR, Cerván AM,
cular and neural sutures, but sensory re-educa- Galán A. Damage control orthopaedics: state of the
tion programmes have shown to be as much art. World J Orthop. 2019;10(1):1–13.
5. Leone J, Bhandari M, Adili A, McKenzie S, Moro
important [17]. JK, Dunlop RB. Predictors of early and late instabil-
ity following conservative treatment of extra-articular
distal radius fractures. Arch Orthop Trauma Surg.
Take-Home Messages 2004:38–41.
• Good knowledge of the upper limb 6. Tang JB, et al. Current practice of primary flexor tendon
repair a global view. Hand Clinic. 2013;29:179–89.
complex anatomy is relevant in surgical 7. Lalonde DH. Latest Advances in wide awake hand
reconstruction of traumas at this level. surgery. Hand Clinic. 2019;35:1–6.
• A complete evaluation of the lesion and 8. Yoon AP, et al. Management of acute extensor tendon
of the traumatized patient (from general injuries. Clin Plastic Surg. 2019;46:383–91.
9. Campbell WW. Evaluation and management
health to functional requests) is funda- of peripheral nerve injury. Clin Neurophysiol.
mental in giving a correct indication to 2008;119:1951–65.
reconstruction or even amputation. 10. Geuna S, Tos P, Battiston B. Essay on peripheral
• The treatment should be given to experi- nerve regeneration. In: International review of neuro-
biology, vol. 87. Elsevier Inc.; 2009.
enced surgeons possibly knowing both 11. Costa AL, Titolo P, Battiston B, Colonna MR. Nerve
plastic and orthopaedic concepts in transfers in distal forearm and in the hand. Plast Aesth
order to give the correct priorities and to Res. 2020;7:32.
choose the best technical solution. 12. Battiston B, Lanzetta M. Reconstruction of high ulnar
nerve lesions by distal double median to ulnar nerve
• Early recognition and management of transfer. J Hand Surg. 1999;24A(6):1185–91.
lesions sometimes involving single tis- 13. Mohan AT, Sur YJ, Zhu L, Morsy M, Peter SW,
sues but often extensively damaging the Moran SL, Mardini S, Saint-Cyr M. The concepts of
upper limb are crucial in getting the goal propeller, perforator, keystone, and other local flaps
and their role in the evolution of reconstruction. Plast
not only of a morphological reconstruc- Reconstr Surg. 2016;138(4):710–29.
tion but mainly of a restored functional 14. Battiston B, Tos P, Clemente A, et al. Actualities in
segment. big segments replantation surgery. J Plast Reconstr
Aesthet Surg. 2007;60(7):849–55.
15. Ciclamini D, Tos P, Magistroni E, Battiston
B. Functional and subjective results of 20 thumb
References replantations. Injury. 2013;44(4):504–7.
16. Adani R, Marcoccio I, Castagnetti C, et al. Long-
term results of replantation for complete ring avulsion
1. Llusa M, Vived AM, Ruano Gil D. Anatomia chirur- amputations. Ann Plast Surg. 2003;51(6):564–8.
gica dell’apparato muscolo-scheletrico. Verduci Ed. 17. Papanastasiou S. Rehabilitation of the replanted upper
2005. extremity. Plast Reconstr Surg. 2002;109:978–81.
2. Durham RM, Mistry BM, Mazuski JE, et al. Outcome
and utility of scoring systems in the management of
the mangled extremity. Am J Surg. 1996;172:569–74.
Lower Limb Trauma
17
Mario Cherubino, Tommaso Baroni,
and Luigi Valdatta
Background
matrices, locoregional flaps, microvascular free
The ability to move in space was a con- flaps, and bone, arterial, and nerve repair skills
quest of the animal kingdom of the vegeta- (Fig. 17.1).
ble and this in the evolutionary scale and it
was possible since the development of the
limbs. In humans, lower limb surgery Key Points
requires a precise knowledge of anatomical Debridement procedures are the most chal-
structures and physiology in order to be lenging part. Knowledge of what should be
performed successfully. Car accidents, debrided and what should be spared
motorbike accidents, and sports-related requires that the most experienced in the
trauma represent majority of the etiology unit surgeon should be the one that per-
of lower limb trauma. In Italy, open frac- forms it. A complete evaluation of the dam-
tures of the legs are estimated to be 3000 age and the correct classification of the
every year. This is to prevent unnecessary open fracture could be done only after the
amputation, but a fast and correct recovery debridement.
needs to be traded in a specialized center
with competences of orthoplastic.
17.2 History
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 271
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_17
272 M. Cherubino et al.
Recontructive Attempt
Amputation
Immediately
“Damage Control”
Debridement ± Revascularization/Reinnervation + Bone Stabilization (External Fixator) +
Negative Pressure Wound Therapy
Fig. 17.1 Treatment algorithm of the lower limb trauma (Illustrations by Tommaso Baroni)
amputation under ether anesthesia was performed Daniel and Taylor reported the first free flap
by Liston in 1846. In that occasion, in addition, reconstruction of a tibial defect in 1973.
one of his students, Joseph Lister, applied anti- During the First World War amputation, mor-
septic principles based on Pasteur’s findings for tality decreased from 40 to 60% to 12.4% as a
the first time in a clinical setting. result of antisepsis. No techniques were devel-
Regarding bone management, fracture fixa- oped in World War II, but mortality of wound
tion foundations were introduced by Ollier complications further declined. During the
(“closed plaster” technique) in the Franco- Korean conflict, the concept of artery repair as
Prussian War and Orr during World War I. The opposed to artery ligation allowed an overall
first external fixation device was patented in 1942 decrease of amputation rate by 49%.
by Hoffmann, even though as early as 1840, In the modern era, several attempts were made
Malgaigne started to work on the same princi- in order to classify tibial fractures and to create
ples. Danis and Müller developed internal fixa- new scoring systems with the purpose of defini-
tion in the 1950s. Distraction osteogenesis was tively assessing limb salvage versus amputation
initially described by Alessandro Codivilla in criteria. Different schools of thought formed as
1840 and the first bone lengthening device regards reconstruction timing after trauma. Byrd
subsequently designed by Gavriil Abramovič
and Godina supported the idea that early recon-
Ilizarov during the 1960s–1970s. struction was related to a decrease in infection
Soft tissue management owes much to Frank and postoperative complication rate. Conversely,
Hastings Hamilton, following the first cross-leg Yaremchuk emphasized the importance of wound
flap performed in 1854. He also pioneered skin stabilization with serial debridement prior to
grafting in the field of soft tissue reconstruction. reconstruction. At the current state of the art,
17 Lower Limb Trauma 273
despite huge advances in the field of lower limb smaller bone. It is not weight-bearing and is less
reconstruction, no reliable scoring systems have troubling in case of injury, made exception for
yet been developed, and the existing classifica- fractures involving the proximal and distal por-
tions show all their limitations in the accurate tions, since their significance in knee and ankle
patient stratification and trauma management. joint stability, respectively. Consequently, the
middle portion of the fibula can be sacrificed for
reconstructive purposes.
17.3 Surgical Anatomy
Crural fascia
Interosseus membrane
Anterior compartment Tibia
• Anterior tibialis muscle
• Extensor hallucis longus muscle
• Extensor digitonum longus muscle
Lateral Compartment
Transverse intermuscular septerum
• Penoneus longus muscle
• Penoneus brevis muscle
Fibula
Fig. 17.2 Leg compartments and muscles inside (Illustrations by Tommaso Baroni)
17 Lower Limb Trauma 275
Popliteal artery
Lateral plantar
Dorsalis pedis artery artery
Medical plantar artery
Dorsal arch
Plantar arch
purely sensory function and the subsequent is the tibia, and high-energy motor vehicle colli-
minor deficit due to its removal, it is often used as sions are responsible for almost 60% of these
a donor site for nerve grafting. injuries. Associated vascular injuries occur in
The saphenous nerve is the largest cutaneous <1% of all civilian fractures, and the risk of vas-
branch of the femoral nerve. It has no motor cular damage increases with increasing injury
function, and it innervates the anteromedial severity. Minor leg injuries can be due to contact
aspect of the leg and the medial foot through the and high-speed sports.
medial crural cutaneous branches. Along its Approximately 50% of military injuries
course, the nerve communicates with the com- involve the extremities. Most extremity armed
mon fibular nerve. wounds have a penetrating component, typically
Sensibility on the plantar aspect of the foot is resulting from explosions (81%) or gunshot
necessary for normal ambulation, since the full wounds (17%). Only 2% of extremity injuries
force of the body is transmitted to the feet. during combat are due to isolated blunt trauma.
Normal sensibility is required for tactile sensa- Many of these injuries involve multiple func-
tion, perception of the position, and protection of tional components and noble anatomical struc-
pressure-bearing portions of the foot. This tures (such as bone, muscles, nerves and arteries),
implies that loss of the tibial nerve is a relative resulting in a high rate of mangled extremities.
contraindication for lower extremity salvage. The overall incidence of military extremity inju-
Nerve injuries to the lower extremity should be ries is lower than in previous recorded conflicts
repaired at the time of injury, by direct nerve (50%), while the overall rate of vascular injury in
repair or nerve grafting, even though results of modern combat is increased.
nerve reconstruction in the lower extremities are Other minor causes of lower extremity com-
poor (Fig. 17.6). plex wounds are the acute compartment syn-
drome, infections and osteomyelitis, vascular
insufficiency, diabetes mellitus, and tumors that
Key Points require extensive resections.
Furthermore, it is important to keep in
mind that a significant muscle loss of the
leg is not an absolute contraindication to 17.5 Classification
reconstruction and salvage, since adequate
deambulation can be maintained even in The most widely used classification for open
case of ankle fusion. With a no longer fractures is that of Gustilo and Anderson
functioning ankle, in fact, the functional (Table 17.2).
needs of the leg muscles are greatly Grade IIIA injuries are usually treated with
unnecessary (Fig. 17.7, illustrations by debridements, local wound care, skin grafts, or
Tommaso Baroni). simple local flaps. Complex plastic surgery pro-
cedures are reserved for grade IIIB and IIIC
injuries. Although this is the most commonly
applied classification system in the orthoplastic
17.4 Aetiology setting, it remains fairly inadequate to describe
the injury or to evaluate the prognosis of an
The nature and severity of lower extremity inju- open tibial fracture for which the plastic sur-
ries differ between the military and civilian geon is involved. Furthermore, other supple-
settings. mental information needs to be included, such
Civilian extremity injuries most often are as the mechanism and energy of the injury, if a
caused by falls, industrial or work-related acci- degloving of the soft tissue is present, and the
dents, and motor vehicle crashes. The long bone presence of any other concomitant injuries or
that is most commonly involved in open fracture comorbidities. The Byrd-Spicer classification
278 M. Cherubino et al.
Femoral nerve
Sciabic nerve
Tibial nerve
Tibial nerve
Ankle Extensors
Ankle Extensors
Ankle Flexors
• Fibulanis longus
muscle • Soleus muscle
Digital Extensors
• Soleus Muscle
• Extensor • Tibialis posterior
digitonum longus Muscle
• Fibulanis brevis muscle
muscle
Table 17.3 Byrd and Spicer classification of lower Table 17.2 Gustilo and Anderson classification of open
extremity trauma fracture
Byrd and Spicer classification of lower extremity Gustilo and Anderson classification of open fracture
trauma Type Description
Type Description Type Clean wound <1 cm in diameter with simple
Type Low-energy forces causing a spiral or oblique I fracture pattern and no skin crushing
I fracture pattern with skin lacerations <2 cm and Type A laceration >1 cm and < 10 cm without
a relatively clean wound II significant soft tissue crushing. The wound bed
Type Moderate-energy forces causing a comminuted may appear moderately contaminated
II or displaced fracture pattern with skin laceration Type An open segmental fracture or a single fracture
>2 cm and moderate adjacent skin and muscle III with extensive soft tissue injury >10 cm. Type
contusion but without devitalized muscle III injuries are subdivided into three types
Type High-energy forces causing a significantly Type Adequate soft tissue coverage of the fracture
III displaced fracture pattern with severe IIIA despite high-energy trauma or extensive
comminution, segmental fracture, or bone defect laceration or skin flaps
with extensive associated skin loss and Type Inadequate soft tissue coverage with periosteal
devitalized muscle IIIB stripping and bone exposure
Type Fracture pattern as in type III but with Type Any open fracture that is associated with
IV extreme-energy forces as in high velocity IIIC vascular injury that requires repair
gunshot or shotgun wounds, a history of crush
or degloving, or associated vascular injury
requiring repair presence and duration of shock, ischemia time,
and the energy of injury. Other index scores such
skin and muscle injury as well as warm ischemia as the Hanover Fracture Scale and the Limb
time. The Mangled Extremity Severity Score dif- Salvage Index have been proposed. These scores
ferently considers four variables: patient age, can be useful tools in the decision-making pro-
280 M. Cherubino et al.
cess when used cautiously but should not be used projections. After initial evaluation, if a CT scan
as the principal means for reaching difficult deci- is possible and indicated (massive destruction
sions. The Ganga Hospital Open Injury Severity and/or unclear bone fracture), the patient needs
scoring was proposed by S Rajasekaran et al. for then to be treated in the OR.
predicting salvage versus amputation in open Debridement is the keystone of the treatment
type III B injuries and providing management of a lower limb trauma. It should be performed
guidelines depending on the total score. The by the most experienced surgeon of the unit and
authors felt the need for this score due to the var- must be adequate and precise. All the necrotic tis-
ied presentation of type III B injuries, lack of sues and all the compromised muscles need to be
proper management guidelines, and lack of a removed. Only the longitudinal tissue (nerve and
comprehensive scale to determine salvage versus main vessels) can be spared.
amputation in severely injured limbs. However,
the practical use of the assessment scale is still
Key Points
unclear in emergency situations.
The irrigation of the wound needs to be
An interesting review was published by Keller
massive and in a low pressure to assure the
et al. in 1983. He found that comminution, dis-
reaching of a clean wound. Six to seven
placement, bone loss, distraction, soft tissue
liters of low-flow saline solution is the min-
injury, infection, and polytrauma in tibial shaft
imal amount to clean from all some con-
fractures were related to a higher risk of systemic
taminated fragments and residues.
complications, while fracture location or config-
uration and concomitant fibular fracture had no
prognostic significance.
When dealing with lower limb reconstruction, Only after the debridement can the final
important goals have to be considered. A com- assessment of the wound be done. Only at this
plete debridement of all devitalized tissue is nec- point, the open fracture can be classified using
essary, in order to obtain a healthy wound bed. It the Gustillo-Anderson classification. If there is
is equally important to restore stability, structure, no fracture, the Arnez-Kahn-Tyler classification
vascularity, and function, to obliterate possible can be used to determine the evolution of the soft
dead spaces, to provide durable coverage of vital tissue involved (Table 17.4).
structures, and to ensure an acceptable aesthetic
result. Table 17.4 Types of degloving injured and their
management
Types of degloving injury and their management
17.7 Treatment Types of degloving
injuries Management
Limited degloving Minimal tissue excision
The beginning of lower limb trauma treatment
with abrasion/avulsion Free tissue transfer for primary
should start in the emergency room at the patient healing if bones, tendons, and
income. The antibiotics should be administered joints exposed
within 3 h from the injury, even in the site of the Non-circumferential Assessment of vascularity of
trauma. The initial assessment should start imme- degloving injuries degloved flaps
Tissue excision
diately after the stabilization of the general Flap reconstruction or grafts
patient’s condition. Evaluation of the vascular- Circumferential single Re-suturing never!
ization of the limb, the possibility of a compart- plane degloving Excision of flap
ment syndrome, or a massive muscle destruction Assess muscular viability
Wound reconstruction and
should be performed by the orthopedic and plas- coverage
tic surgeons together. As initial assessment, an Circumferential Suffers greater degree of tissue
X-ray exam of the traumatic leg must be per- multiplane degloving disruption
formed to evaluate the bone fractures in standard Staged reconstruction
17 Lower Limb Trauma 281
Bone fixation is the next step, performed by be treated with a local flap, (including options
the trauma/orthopedic surgeon, and can be tem- such as propeller or other local perforator flap
porary or definitive. It depends on the contamina- which requires microsurgical skills, avoiding the
tion of the bone, the lack of bone tissue, the state anastomosis) or a free flap.
of the bone itself, and the possibility to recon-
struct right afterward. In most of the time, an
external fixation is preferred in case of open Tips and Tricks
fracture. The correct hemostasis is necessary before
The next step is represented by soft tissue starting the negative pressure therapy.
reconstruction. If it is possible and if there is a Sometimes, it is better to postpone the
clear and definite wound, soft tissue closure beginning of the negative pressure therapy
should be performed immediately. The choice of by a few hours (up to 24 hours) to stop the
the technique depends on the characteristics of bleeding in the damaged field. The damage
the wound. If primary closure can be easily control concept allows to repeat the
achieved, it is the best choice and should be per- debridement that should be performed as
formed if no sign of infection is present. However, soon as possible from the trauma, but also
in the lower third of the leg, a primary closure is must be repeated after a few days to allow
not generally possible, due to the lack of soft tis- the maximal expert of the unit to be present
sue, in particular in case of a high-energy trauma. at the surgery.
If there is a loss of tissue substance and a more
complex reconstructive procedure is needed.
The correct reconstructive procedure is cho-
sen, again, considering the characteristics of the 17.8 Clinical Cases (Figs. 17.8, 17.9,
wound. A clear, superficial wound, without any 17.10, and 17.11)
bone exposure, can be treated with a skin graft
(split thickness or full thickness); however, deep
or complex wounds require a more stable and Take-Home Messages
demanding reconstruction. In the lower limb trauma, the lower leg open
The dermal substitute is a reality in clinical fractures management is a challenge both
practice for the treatment of lower limb. They for the orthopedic and plastic surgeons.
have different characteristics; however, they rep- Nowadays, the orthoplastic approach, with a
resent a valid choice in case of a deep not com- close collaboration and synergy of compe-
plex wound. If the bone or the tendon exposure is tences between the orthopedic and plastic
limited, a simple dermal substitute guarantees an surgeons, represents the gold standard for
easy and fast procedure to reconstruct the defect. treatment. This requires planning and acting
In case of wide superficial defects, where the skin with synergy, starting from the access of the
is lost due the trauma (degloving injury) but the patient in the emergency room. The debride-
muscular fascia is preserved, the dermal substi- ment represents the keystone, and damage
tute guarantees a softer and more pliable finale control is the following step. An adequate
cover compared to a direct splint thickness graft. reconstruction of the soft tissue can be per-
If a flap is required, it can be a local or a free formed after a few days, and the correct
flap based on the experience of the surgeons and techniques can be chosen based on the char-
the dimension and the etiology of the trauma. acteristics of the wound.
Low energy, with a small dimension defect, can
282 M. Cherubino et al.
a b c
Fig. 17.8 A 57-year-old patient is in the hospital after a motorbike accident. (a) Initial evaluation shows wounds of
inferior left limb. (b) X-rays reveal tibial and peroneal fractures. (c) Confirmed by CT scan
17 Lower Limb Trauma 283
a b
Fig. 17.9 (a) In the operating room, the patient was (b) an anterolateral thigh free flap from the contralateral
treated with initial debridement and damage control with thigh was harvested and used to reconstruct the leg defect
an external fixator for the bone alignment and negative to guarantee a stable and viable cover of the fracture
pressure device for control of the wounds. After 5 days,
a b c
Fig.17.11 (a) Early and final aspect of the inferior limb. The contralateral thigh shows scars due the donor site. (c)
The external fixator was used to let the bone heal. (b) The X-ray shows complete bone healing
inferior leg after 6 months shows a complete recovery.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 285
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_18
286 E. Rossella et al.
cooking, or inherently unsafe cookstoves, bines with the zone of coagulation. Surrounding
which can ignite loose clothing. the zone of stasis is the outer zone of hyperemia,
• Age: children under 5 years old are particu- which contains viable tissue. Vascular perfusion
larly vulnerable to burns. They account for is increased in response to inflammatory status.
75% of all pediatric burns. Among all children, The damage directly induced by the thermal
scald burn accounts for about two-thirds of agent can deepen due to the occurrence of addi-
burn injuries. tional factors: progressive drying of superficial
• Socioeconomic factor: major burn trauma layers, extension of the thrombotic phenomena,
occurs mainly among the poor and the dis- stasis produced by the edema, and bacterial con-
abled in poor neighborhoods and in low- tamination. This is the reason why the exact diag-
income countries. nosis of depth is not obvious initially; the final
• Other risk factors include, for adults, smok- depth becomes clear 48–72 h after the injury.
ing, alcoholism, psychiatric disorders and
neurological disease as epilepsy, occupations
that increase exposure to fire, use of kerosene 18.4 Clinical Evaluation
(paraffin) as a fuel source for non-electric
domestic appliances, and inadequate safety It is essential to be able to promptly identify the
measures for liquefied petroleum gas and severity of a burn as it affects the correct thera-
electricity. peutic orientation. The burns’ gravity is diag-
nosed based on the following parameters:
4.5% 4.5%
18% 18%
4.5%
4 .5 %
4.5%
4.5
%
9% 9%
1%
4.5
4.5
%
4.5%
18% 18%
%
4.5
%
9% 9% 9% 9%
7% 7% 7% 7%
Trunk (half) 2¾ 3¼ 4 4¼ 4½
Fig. 18.1 Burn extension according to the Wallace Rule of Nine (upper). The table shows an estimation of the burn size
(% of TBSA) according to the Lund and Browder method in the pediatric population
painful, red, blistered, moist, soft, and blanch thetic level. Remember also to ask for an oph-
when touched. Examples include burns from thalmologic consultation. Additional critical
hot surfaces, hot liquids, or flame. Full-thickness areas are hands, joint surfaces, the genitals,
burns extend through both the epidermis and and perineal areas due to the increased infec-
dermis and into the subcutaneous fat or deeper. tious risk (a urethral catheter or, eventually,
These burns have little or no pain; can be white, rectal should be placed) (Fig. 18.3).
brown, or charred; and feel firm and leathery to • Age (young children <5 years and elderly
palpation with no blanching. These occur from patients >75 years), preexisting comorbidi-
a flame, hot liquids, or superheated gasses (Fig. ties, and/or associated injuries represent addi-
18.2; Table 18.1). tional negative prognostic factors.
Note that superficial burns without blister
formation areas are not included in the TBSA
burn calculation. Tip and Tricks
• Critical Areas Remember to check signs of inhalation
Face and neck are considered areas of risk. injury if there is a history of flame burns or
The burn can be associated with inhalation of burns on the face or if there is a change in
gases and vapors with damage to the upper voice with hoarseness or harsh cough [5].
airways; the result could be pharyngo- Remember to check the extremities in
laryngeal edema that requires prompt treat- case of circumferential burns for the exis-
ment. In these regions, the scarring results are tence of distal vascular compromise. Total
also invalidating both on a functional and aes-
288 E. Rossella et al.
a b
c d
Fig. 18.2 Typical appearance of skin burns of different mixed white, pearly appearance. Note the importance of a
depth. Panel a: Superficial hyperemic burn. Panel b: prompt insertion of a urinary catheter when genitalia is
Intermediate-partial thickness burn presenting with blis- involved in the thermal injury. Panel d: Full-thickness
ters. Panel c: Intermediate-deep burn presenting with burn of both feet with a typical charmed aspect
Table 18.1 Burn injury classification according to depth
Depth of burn Tissue involvement Clinical signs Sensation Healing time Sequelae
Superficial Epidermis Erythema Painful 7 days by No scarring sequelae
No blisters re-epithelialization from A pigmented area
Blanches with viable keratinocytes within can remain if the
pressure dermal glands and hair area is not
follicles adequately protected
from sun exposure
Epidermis
Papillary dermis
Reticular dermis
18 Burns: Classification and Treatment
Subcutaneous tissue
Intermediate-superficial Epidermis and Pale pink to cherry Painful because 14 days by Possible color match
papillary dermis red of exposed re-epithelialization from defect
Blisters superficial viable keratinocytes within Low to moderate risk
Blanches with nerves dermal glands and hair of hypertrophic scar
pressure follicles
Epidermis
Papillary dermis
Reticular dermis
Subcutaneous tissue
289
Table 18.1 (continued)
290
Depth of burn Tissue involvement Clinical signs Sensation Healing time Sequelae
Intermediate-deep Epidermis and Mixed white, Little or no Up to 21 days. Closure by Moderate to high
dermis down to pearly; dark pink pain epithelialization may not risk of hypertrophic
reticular dermis No blisters occur. Need for surgical scars and scars
Epidermis Fixed capillary intervention contracture
Papillary dermis staining
Reticular dermis
Subcutaneous tissue
Deep Whole skin and, White, waxy, or Insensate No spontaneous healing Wound contraction
eventually, deeper charred. because of Need for surgical Severe contracture
Epidermis tissues No blisters destruction of intervention deformities
Papillary dermis No capillary refill nerve endings
Reticular dermis
Subcutaneous tissue
E. Rossella et al.
18 Burns: Classification and Treatment 291
but such syndromes occur after 12–18 h and are under specific circumstances, additional special-
preferably treated in a burn center. ized tests are appropriate: arterial blood gases
with carboxyhemoglobin level (carbon monox-
• Circulation and cardiac status with hemor-
ide) if inhalation injury is suspected and ECG
rhage control.
with cardiac enzyme in case of electrical burns or
• Disability, neurological deficit, and gross
preexisting cardiac problems.
deformity assessment.
A urinary catheter should be inserted to estab-
• Exposure and environmental control (com-
lish fluid balance monitoring. Antithrombotic
pletely undress the patient, examine for asso-
and anti-acid treatments should be started.
ciated injuries, and maintain a warm
Morphine (or opioid equivalents) are indicated
environment).
for control of pain associated with burns. Pain
A thorough assessment should then take into should be differentiated from anxiety.
account: type of burn (e.g., flame, electrical, radi- Benzodiazepines may also be used to relieve the
ation, chemical), depth and %TBSA, coexisting anxiety associated with the burn injury. Unless
medical conditions, and social circumstances. contraindicated by spine immobilization, elevate
These evaluations are essential to understand the patient’s head to 45 degrees. This will help
whether a patient should be referred to a Burn minimize facial and airway edema and prevent
Center or not. aspiration. Similarly, elevating the affected
extremities reduces edema.
Key Point
The American Burn Association recom-
18.7 Fluid Resuscitation
mends burn center referrals for patients
with:
Crystalloid fluid is the cornerstone of resuscitation
• Partial thickness burns greater than 10% for burn patients. The amount of replacement fluid
of total body surface area. is predicted from the extent of burn and size of the
• Full-thickness burns. patient, and fluid replacement should proceed at
• Burns of the face, hands, feet, genitalia, the same rate of the loss. Lactated Ringer’s (LR) is
or major joints. the fluid of choice for burn resuscitation because it
• Chemical and electrical burns or light- is widely available and closely resembles intravas-
ing strike injuries. cular solute content. Hyperchloremic solutions
• Significant inhalation injuries. such as normal saline should be avoided.
• Burns in patients with multiple medical By consensus, the American Burn Association
disorders. published a statement in 2008 establishing the
• Burns in patients with associated trau- upper and lower limits from which the 24-h post-
matic injuries. burn fluid estimates could be calculated. These
limits were derived from the two most commonly
applied resuscitation formulas: the Parkland for-
At the hospital, a peripheral intravenous mula and the modified Brooke formula. For any
access should be established, preferably through traditional formula, it was estimated that one-half
unburned skin. This avoids the complications that of the calculated total 24-h volume would be
may ensue with central lines, such as pneumotho- administered within the first 8 h post-burn, calcu-
rax (subclavian a), inadvertent arterial injury lated from the time of injury. The traditional for-
(femoral a), and venous thrombosis. In elderly mulas further estimated that the remaining half of
patients, patients with cardiorespiratory disease the calculated total 24-h resuscitation volume
and patients who have delayed presentation, con- would be administered over the subsequent 16 h
sider inserting a central venous pressure line. of the first post-burn day. After the initial rate of
Baseline screening tests are often performed; fluid resuscitation has been determined, fluids
18 Burns: Classification and Treatment 295
should be adjusted on the basis of urine output A final strategy is to reduce catabolism and
(with a target urine output of 0.5 ml per kilogram increase muscle mass by providing anabolic
of body weight per hour for adults). Administration agents. Insulin, insulin-like growth factor 1, and
of albumin and other colloids is usually avoided growth hormone have all been shown to have a
in the first 24 h post burn, but they may have a benefit but are rarely used. Minimizing pain and
role in severe burns after the first 24 h. High-dose distress also reduces the metabolic demand.
vitamin C (66 mg per kilogram per hour) has also
been reported to reduce fluid needs, but there are
questions about whether it works primarily as 18.9 Management of the Burn
diuretic. Wound
Splints can also provide support and comfort surgical debridement are that it often results in
for extremities’ burned areas. significant blood and heat loss. Indeed, it is vital
to have multiple units of packed red blood cells
Deep partial- or full-thickness burns need an and plasma type and cross-matched preopera-
operative wound closure. The main goals of sur- tively. Moreover, steps can be taken to avoid
gical treatment are removal of damaged or devi- excessive blood loss using tourniquets, com-
talized tissue (debridement) and replacement pressive dressings, limb elevation, infiltration,
with viable tissue. It has been established that topical application of epinephrine solutions,
early removal of the necrotic tissue decreases electrocautery, or topical hemostatic agents
wound infection and mortality. The burned and (recombinant thrombin or fibrinogen). The
dead tissue of partial-thickness and full-thickness additional critical issue related to the surgical
burns create an opportunistic environment for debridement is its poor selectivity that results in
gram-positive cellulitis to occur and leads to the viable skin or healthy tissue being sacrificed
sequelae of the wound burden, including slow along with the necrotic skin (Fig. 18.4).
healing time, physiologic impairment, contrac- • Hydrosurgical debridement (e.g., water jet
tures, and functional deficit. At the same time, and high-powered parallel water jet tools) is
open wounds lose heat and fluids, contributing to another useful tool in surgical debridement. It
the patients’ hyperdynamic hypermetabolic works by producing a high-pressure jet of
response. Surgeons have to overcome two prob- water across an aperture in an angled hand-
lems: the physical insult of the debridement and, piece. The Venturi effect creates a vacuum that
occasionally, large % TBSA, the limited source removes surface debris which is sucked into
of replacement skin. the machine together with the irrigation fluid.
The cutting and aspiration effects can be con-
trolled by adjusting console power settings,
18.10 Debridement handpiece orientation, and handpiece pres-
sure. The vacuum that is created by the speed
of the jet aims to lift only nonviable tissue, and
The order of excision is dependent on the surgeon,
thus maximal dermal preservation could be
but the goal is to safely excise and debride the larg-
achieved. Only eschars that are deep, hard,
est surface areas first, such as the anterior or poste-
dry, or leathery are not easily debrided and
rior trunk or large areas on the extremities. The
require multiple passes as well as higher pres-
size of the primary excision largely depends on the
sure settings or may still need cold knife exci-
amount of available autograft or skin substitute, as
sion (Fig. 18.4).
it is essential to cover the excised and debrided
areas. Generally, no more than 10–20% TBSA is
excised at one time to prevent excessive blood loss
and allow for complete coverage [9]. Key Point
NexoBrid® (Mediwound Ltd.), a form of
• Conventional surgical debridement of acute debriding gel dressing (DBD), has gained
burn wounds has consisted of sharp tangential popularity in recent years. It is a form of
excision of nonviable tissue with handheld bromelain-based enzymatic debridement
knives such as the Goulian or Weck knife. agent that is derived from pineapple stems.
Tangential excision of burned tissue involves Its effects on burn wounds particularly deep
unroofing the burn eschar and debriding the partial- and full-thickness wound have been
dead tissue layer by layer until encountering evaluated in several studies [10, 11] Its ben-
healthy bleeding tissue. This approach is efits mainly are due to eschar removal with-
opposed to a fascial excision, which is an exci- out removing any viable or healthy tissue,
sion of all skin elements to the subcutaneous fat/ leaving a clean dermal/subdermal tissue,
fascia and can be considered in case of obvious preparing the wound for closure.
full-thickness injuries. The disadvantages of the
18 Burns: Classification and Treatment 297
a b
Fig. 18.4 Panel a: tangential debridement with dermatome. Panel b: hydrosurgical debridement
a b
Fig. 18.5 Panel a: Severe burn injury affecting more is removed in a non-traumatic manner. The wound is
than 20% of the TBSA with intermediate-deep and full- wiped with a large sterile dry gauze, followed by a normal
thickness burns. A bromelain-based enzymatic debride- saline-soaked gauze until a pinkish surface with bleeding
ment of the 15% of TBSA was planned soon after the points or whitish tissue is seen
patient admission. Panel b: After 4 h, the dissolved eschar
18 Burns: Classification and Treatment 299
a b
c d
Fig. 18.7 Panel a: Intermediate-partial thickness burn. dressing 10 days after application. Note the optimal con-
Panel b: Wound coverage with advanced medial dressing trol of exudation. Panel d: spontaneous healing 15 days
(alginate). Panel c: Appearance of the advanced medical post injury
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 303
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_19
304 S. Carella and M. G. Onesti
Table 19.1 Classification of chemotherapy drugs according to their ability to cause local damage after extravasation
DNA-binding Non-DNA binding
Vesicants Alkylating agents Alcaloids of Vinca
Mechlorethamine Vincristine
Bendamustine Vinblastine
Anthracyclines Vindesine
Doxorubicin Vinorelbine
Daunorubicin Vinflunine
Epirubicin Taxanes
Idarubicin Docetaxel
Antibiotics Paclitaxel
Dactinomycin Others
Mitomycin Trabectedin
Cabazitaxel
Trabectedin
Irritans Alkylating agents
Carmustine
Ifosfamide
Streptozocina
Dacarbazine
Melphalan
Antracyclines
Liposomal oxorubicin
Liposomal aunorubicin
Mitoxantrone
Topoisomerase II inhibitors
Etoposide
Teniposide
Topoisomerase I inhibitors
Irinotecan
Topotecan
Antimetabolites
Fluorouracil
Platinum salts
Carboplatin
Cisplatin
Oxaliplatin
Non-vesicants Arsenic trioxide
Asparaginase
Bleomycin
Bortezomib
Cladrabine
Cytarabine
Eribulin
Etoposide phosphate
Gemcitabine
Fludarabine
Interferons
Interleukin-2
Methotrexate
Monoclonal ntibodies
Pemetrexed
Pentostatin
Raltitrexed
Temsirolimus
Thiotepa
Cyclophosphamide
19 Extravasation 305
Table 19.2 Risk factors for extravasation ing to their ability to cause local damage after
Infusion Type of catheter Pharmacological extravasation into three categories: vesicants,
procedure- Cannula size factors non-vesicants, and irritants (Table 19.1) [17, 18].
related selection Type of drug “Vesicants” are agents that have the potential
Poor cannula Excipients
fixation Osmolarity to cause blistering, skin sloughing, tissue necro-
Unfavorable Concentration sis, and a diffuse damage to the perivasal tissue.
cannulation site Volume They can be sub-classified into DNA-binding
(hand dorsum, Ph drugs and DNA-non-binding drugs. The agents
antecubital fossa, Vasoconstrictive
site in proximity of potential that bind to the DNA in the cells are responsible
joints, tendons, and Cytotoxicity of prompt cell death and, by remaining in the tis-
neurovascular sue, lead to a progressive tissue injury and necro-
fascicules) sis. The components of the drug are released
Multiple attempts at
cannulation from dead cells in the tissue and are taken up by
Duration adjacent healthy cells through endocytosis. This
Patient- Skin color Conditions process of cellular uptake of extracellular sub-
related Hypotension associated with stances sets up a continuing cycle of tissue dam-
Obesity impaired
Extreme ages circulation
age, and the drug is retained in the tissue for a
(fragile veins, in Raynaud syndrome, long period and recirculates in the surrounding
child and old people, Diabetes mellitus, area. The wound healing process is obstacled by
altered mental superior cava the progressive tissue damage, and extravasation
status) syndrome, severe
Communication peripheral vascular
lesions become larger in size, deeper, and more
difficulties of pain disease, painful over time resulting in chronic ulcer.
(sedation, intubation, lymphedema, Agents that are not bound to DNA are metabo-
young children) radiodermatitis lized in the tissue and more easily neutralized
Endothelium Excessive patient
alterations(elderly movements, blood
than DNA-binding agents. They generally don’t
patients, clot formation at cause tissue necrosis; the damage they cause
atherosclerosis, cannula site remains localized, and it is associated with a
arterial hypertension, mild-to-moderate pain. Tissue repair follows a
advanced diabetes)
normal healing process [10]. “Non-vesicants” do
Staff- Inexperienced staff
related Knowledge lack of vesicant drugs not cause inflammation or tissue necrosis. The
Distraction or missing check during “irritants” can cause pain at the infusion site and
infusion and/or during shift change along the course of the vein chosen for the infu-
Common Terminology Criteria for Adverse Events, sion. They may be responsible for painful local
CTCAE, V5 irritation of the venous endothelium, with reflex-
ive vasospasm, which can cause obstacle to blood
also the healthy tissue, involving vessels, nerves, flow with a high risk of extravasation. They are
tendons, and muscles with severe sequelae [17]. often associated with chemical phlebitis.
Between the 1940s and the 1970s, the antitu- Risk factors for extravasation are related to the
mor drugs were administrated in monochemo- chemotherapeutic agent, infusion procedure,
therapy for a palliative scope in case of advanced patient, and staff [8, 9] (Table 19.2). Peripheral
cancer always following surgery and/or radiant rather than central venous administration of anti-
therapy. In the 1960s and early 1970s, a major neoplastic agents is more likely to be associated
breakthrough in cancer therapy occurred. The use with frequent cannulation, which is a risk factor
of multiple drugs administered simultaneously in for extravasation, and this should be avoided.
polychemotherapy showed encouraging results. There are various patient factors that contribute
It was at this time that the reporting about anti- to the aetiology of extravasation injuries. Veins of
blastic drugs extravasation was common. people receiving chemotherapy for cancer are
Chemotherapy agents may be classified accord- often fragile, mobile, and difficult to cannulate
306 S. Carella and M. G. Onesti
[8–10]. Patients who receive chemotherapy at the increases the risk for extravasation. These tiny
same site as radiotherapy may experience a reac- patients require especially effective pressure-
tivation of skin toxicity known as “recall” phe- sensitive equipment for the early detection of
nomenon [19], and patients who have had an extravasation injury, and an invasive treatment
extravasation and receive further chemotherapy should be avoided, whenever possible. Common
in a different site may experience an exacerbation sites of extravasation injuries in neonatal and
of tissue damage in the original site [20, 21]. pediatric patients include the dorsum of the hand,
Patients who have undergone radical mastec- the forearm, the cubital fossa, and the dorsum of
tomy, axillary surgery, or lymph node dissection the foot and scalp. These are the areas of the body
may have impaired circulation in a particular where the skin and subcutaneous tissue are thin-
limb, which reduces venous flow and may allow nest, which makes them the most suitable sites
intravenous solutions to pool and leak out. for IV access but also the most susceptible to
Sites most often implicated in extravasation injury [3, 4, 23]. However, no site is immune
injuries include the dorsum of the hand and foot, from the possibility of an extravasation injury.
ankle, antecubital fossa, and near joints or joint
spaces [1, 2, 5].
There is no standard treatment for the acute 19.1.3 Chemotherapy Extravasation
phase of extravasation injury. Treatment proto- Injury Classification
cols for extravasations vary from conservative to
aggressive management of the acute injury [2, 8, Extravasation injuries may range from erythema-
10, 12–14, 16], with additional variations in tous reactions (Fig. 19.1) to skin sloughing and
wound management. necrosis (Fig. 19.2). Early symptoms may be
pain, itching, tingling, and burning sensation.
Swelling, edema, erythema, induration,
19.1.2 Extravasation Injury sloughing, and blistering could represent early
in Neonatal and Pediatric signs (Fig. 19.3). Late signs may include ulcer-
Patients ation and tissue necrosis (Fig. 19.4). According
to the latest Common Terminology Criteria for
Extravasation injury represents a complication Adverse Events [24], extravasation can be divided
commonly seen in the neonatal intensive care into five grades depending on the clinical gravity
unit, and it can cause scarring with cosmetic and of damage because of toxic drugs (Table 19.3).
functional sequelae. Most injuries (70%) Signs and symptoms are not always constant and
occurred in infants of 26 weeks gestation and less do not always occur immediately after extravasa-
[3, 4]. tion. In some cases, we can experience the so-
IV fluids and medications commonly impli- called “silent” extravasation, showing signs of
cated in extravasation injuries include parenteral extravasation only a few days after the injury. If
nutrition fluids, cytotoxic drugs, vasopressors,
inotropes, electrolytes (e.g., calcium chloride),
and hyperosmolar medications. The most fre-
quent causative agents are parenteral nutrition
and IV antibiotics [3, 4, 22]. The neonatal and
pediatric population is more susceptible to
extravasation injuries, due to their smaller and
thus more fragile veins. Further, their immature
and fragile skin is predisposed to a major gravity
of the damage. Newborns are also unable to
express to the medical staff any pain they are suf- Fig. 19.1 Erythematous reaction after 6 days from
fering; therefore, inadvertent continuous infusion extravasation marked with a dermographic pencil
19 Extravasation 307
Fig. 19.2 Extensive tissue necrosis of the dorsum of by tissue necrosis, with ulcer formation. The
hand after Doxorubicin extravasation
characteristics of an extravasation injury are the
unpredictability of its evolution and the chronic-
ity, because, depending on the type of agent, the
substance responsible for the damage can be
retained in the tissue for a long time [12–14].
a b
Fig. 19.5 (a) Antiblastic extravasation injury after 11 h on the site of central venous access marked with a dermo-
graphic pencil. (b) Result after saline infiltration, 2 weeks after the injury
a b
Fig. 19.6 (a) Ulcer of the dorsum of the wrist after extravasation of antiblastic drug in a 58-year-old male patient. (b)
Repairing with regional pedicled flap. (c) Result at 6 months
amount of saline solution is around 20–30 mL for of edema and extended lesions, a washout tech-
the hand; 20–50 mL for the forearm; and nique should be performed. This technique con-
40–90 mL for antecubital fossa. After infiltration, sists of infiltration of saline solution that allows
application of a steroid cream is provided. The irrigation of the wound and free flow drainage of
infiltration is usually administered three times a the extravasated fluid through small skin punc-
week until clinical improvement. The affected ture holes made with a needle in the area around
area is covered with sterile gauzes and a bandage. the lesion. Silver sulfadiazine should be used in
In case of ulceration and necrosis observed at case of blistering and to prevent infections. In
baseline, a debridement using chemical collage- some cases, it is possible to observe eschar
nases based on hyaluronic acid and/or escharot- formation at 1 or 2 weeks after extravasation.
omy should be performed. Where primary closure This is treated with collagenases or escharotomy.
was not possible, autologous skin graft, dermal In cases of partial- and full-thickness wounds,
substitute, local and regional pedicled flaps application of our treatment protocol and autolo-
(Fig. 19.6a–c), and free flap should be considered gous skin grafts, dermal substitute, or local flaps
depending on defect size. can be used to repair the injuries. Neonates and
infants are vulnerable populations requiring spe-
19.2.2.2 Neonates and Infants cial attention, and every procedure should be as
The saline solution injected is in total up to 10 or much minimally invasive as possible. The devel-
20 mL; it is infiltrated around the affected area, opment of dermal substitutes and products of
with a thin needle, delivering a small amount of regenerative surgery allowed us to choose for less
saline solution per each site of injection. In case traumatic therapeutic options. They may acceler-
310 S. Carella and M. G. Onesti
a b
Fig. 19.7 (a) Estravasation injyry due to hypertonic solu- debridement and application of dermal substitute.
tion. (Reproduced with permission from Wolters Kluwer (Reproduced with permission from Wolters Kluwer
Health, Inc.) (b) Result at 21 days following wound Health, Inc)
20. Valencak J, Troch M, Raderer M. Cutaneous recall 26. Montgomery LA, Hanrahan K, Kottman K, Otto A,
phenomenon at the site of previous doxorubicin Barrett T, Hermiston B. Guideline for i.v. infiltrations
extravasation after second-line chemotherapy. J Natl in pediatric patients. Pediatr Nurs. 1999;25(2):167–9,
Cancer Inst. 2007;99(2):177–8. 173–180.
21. Alley E, Green R, Schuchter L. Cutaneous toxicities of 27. Simona R. A pediatric peripheral intravenous infiltra-
cancer therapy. Curr Opin Oncol. 2002;14(2):212–6. tion assessment tool. J Infus Nurs. 2012;35:243–8.
22. Wilkins CE, Emmerson AJB. Extravasation inju- 28. Bahrami M, Karimi T, Yadegarfar G, Norouzi
ries on regional neonatal units. Arch Dis Child Fetal A. Assessing the quality of existing clinical practice
Neonatal Ed. 2004;89(3):F274–5. guidelines for chemotherapy drug extravasation by
23. Tong R. Preventing extravasation injuries in neonates. appraisal of guidelines for research and evaluation
Pediatr Nurs. 2007;19(8):22–5. II. Iran J Nurs Midwifery Res. 2019;24(6):410–6.
24. US Department of Health and Human Services, 29. Onesti MG, Carella S, Maruccia M, Marchese C, Fino
National Institutes of Health, National Cancer P, Scuderi N. A successful combined treatment with
Institute. Common terminology criteria for adverse dermal substitutes and products of regenerative medi-
events (CTCAE). (v5.0, Nov 2017). cine in a patient affected by extravasation injury from
25. Millam DA. Managing complications of i.v. hypertonic solution. In Vivo. 2012;26(1):139–42.
therapy (continuing education credit). Nursing.
1988;18:34–43.
Radiodermatitis: Prevention
and Treatment
20
Diego Ribuffo, Federico Lo Torto,
and Marco Marcasciano
Background
20.1 Introduction
Skin alterations due to radiation were reported
Ionizing radiations cause both direct cellular
since the beginning of the twentieth century.
damage acting on DNA and proteins and indirect
They have been associated with various diag-
damage, thanks to reactive oxygen species cre-
nostic and interventional medical procedures
ation. According to the fundamental law of radio-
and occupation-related environments. Above
biology “Law of Bergonié and Tribondeau,”
all, radiotherapy used in cancer treatment rep-
actively proliferating cells as stem cells or epi-
resents the main cause [1].
dermis basal cells are particularly radiosensitive
In 2018, there were more than 18 million
[6]. Therefore, the skin presents a great suscepti-
of total cancer cases estimated worldwide
bility to radiation-induced damage [7].
[2]. About 50% of them are scheduled for
radiation therapy, and some degree of radio-
dermatitis will occur in 95% of cases [3]. In
Key Point
particular, skin problems arise when head
Being composed of actively proliferating
and neck region, perineum, or breast cancers
cells, the skin is particularly a radiosensi-
are treated with ionizing radiation [4].
tive organ.
Patient’s well-being and quality of life can be
impaired by these side effects, and their can-
cer treatment may be inappropriate if pauses
or quit of therapy becomes necessary [5]. Skin pathologic changes due to ionizing radia-
tions are commonly defined as radiodermatitis
(RD), and they occur as a deterministic effect,
when the threshold level of exposure is surpassed
[8]. Severity and progression of damage depend
D. Ribuffo on treatment-related and patient-related risk fac-
Sapienza University, Rome, Italy
e-mail: [email protected]
tors. Total radiation dose, its fractionation and
type of external beam, irradiated site and surface
F. Lo Torto (*)
University of Rome Sapienza, Rome, Italy
area, eventual radiosensitizers, and chemother-
apy are all treatment-related factors, while eth-
M. Marcasciano
Breast Unit Integrata di Livorno, Cecina, Piombino,
nicity, sex, age, body mass index, smoking habit,
Elba, Azienda USL Toscana Nord Ovest, comorbidities, ultraviolet exposure, hormonal
Livorno, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 313
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_20
314 D. Ribuffo et al.
status, and genetics represent patient-related fac- motion and significantly impair patient’s quality
tors [9]. of life [19].
Due to great variability in timing and assess- Acute and chronic RD manifestations are not
ment of RD’s presentation, it is fundamental to linked, and severity of acute injuries does not
rule out differential diagnosis and exclude cases predict chronic RD development [20].
of contact dermatitis, dermatophytosis, radiation
recall dermatitis and some cutaneous hypersensi-
tivity syndromes as erythema multiforme, Key Point
Stevens–Johnson Syndrome, and toxic epidermal RD is defined acute when it occurs within
necrolysis [10]. the first 90 days of ionizing radiations
exposure, while skin alterations that hap-
pen over 90 days after exposure are defined
20.2 Clinical Presentation chronic RD. Acute and chronic RD are not
and Classification linked nor in occurrence nor in severity.
Table 20.1 CTCAE 4.0 grading of acute radiation Supportive Care in Cancer (MASCC) published a
dermatitis review and proposed some general clinical guide-
Grade Clinical presentation lines for acute and chronic RD management [26].
0 No change over baseline/no symptoms
1 Faint erythema or dry desquamation
2 Moderate to brisk erythema, patchy moist Key Point
desquamation, mostly confined to skin folds To date, there is no consensus for RD pre-
and creases, moderate edema vention and treatment, but Multinational
3 Moist desquamation other than skin folds and
creases, bleeding induced by minor trauma or
Association for Supportive Care in Cancer
abrasion (MASCC) published some general clinical
4 Life-threatening consequences, skin necrosis or guidelines.
ulceration of full-thickness dermis, spontaneous
bleeding from involved site, skin graft indicated
Similarly, systemic oral therapy with proteo- of damage. Scarce vascularization reduces grafts’
lytic enzymes as papain or trypsin, oral sucral- survival abilities and makes their use limited to
fate, zinc, and pentoxifylline is not supported by chronic ulcers of the hands’ dorsum in profes-
sufficient evidence to recommend its preventive sional RD.
usage in radiated patients. Pedicled flaps, myocutaneous flaps in particu-
In order to prevent skin damages in women lar, may be used to cover the injury with non-
that undergo radiotherapy for breast cancer treat- radiated and well-vascularized tissue (Figs. 20.1
ment, the MASCC panel evidenced weak recom- and 20.2).
mendation supporting the use of silver Free flaps are hazardous in these patients for
sulfadiazine cream. their vascular impairment, but technical innova-
Regarding RD treatment, various wound tions are making microsurgery applicable in
dressings have been proposed along the years: chronic RD treatment [28–30]. Indeed, ionizing
dry dressing, hydrous lanolin gauze, hydrocol- radiation is associated with fibrosis, impaired tis-
loid dressings, moisture vapor permeable dress- sue healing, and diminished vascularity. Wide tis-
ings (Tegaderm™), and gentian violet-based sue excision is necessary before a free flap is
dressing. Despite their diffusion, the recent transferred, and vascular anastomosis has to be
review did not find evidence pro- or against those performed at certain distance from radiated site,
dressings’ efficacy. Alike, less known topic for a reliable recipient vessel may be hard to find
agents as sucralfate cream, hydrocortisone, and dissect (Figs. 20.3, 20.4, and 20.5) [31].
honey, and trolamine did not met sufficient evi-
dence for their recommendation.
Key Point
Facing chronic RD effects, long-pulsed dye
Radiated tissues present compromised vas-
laser (LPDL) has been proven to have light effi-
cularization even in peripheral areas that do
cacy treating telangiectasia.
not present clinical signs of damage. Before
Pentoxifylline and vitamin E have been used
reconstruction with a free flap, radiated tis-
in an attempt to treat radiotherapy-induced fibro-
sues must be excised widely, in order to
sis (RIF), but there is insufficient evidence to
find reliable recipient vessels for vascular
support a recommendation for or against them, at
anastomosis.
present. Other therapeutic options have been pro-
posed for the difficult management of RIF, such
as physiotherapy, pharmacotherapy, hyperbaric
oxygen, and laser therapy, but they all lack scien- In 2007, Rigotti et al. were the first to show
tifically proven efficacy. the beneficial effects of fat grafting in irradiated
There is no standard management protocol for skin [32]. Since then, therapies based on autolo-
chronic RD-induced skin ulcers. A multidisci- gous stem cells gained popularity in chronic RD
plinary approach is useful, in selecting the most management. Autologous adipose tissue grafts
suitable treatment. The radiation oncologist, are easily harvested, and they contain stem/pro-
wound care specialist, dermatologist, and plastic genitor cells (ASC) in the stromal vascular frac-
surgeon should all take care of the patient [27]. tion. Once injected in the radiated tissue, ASC
In cases of chronic ulcers that do not respond organize and differentiate, thus promoting the
to ambulatory wound dressings, surgical debride- secretion of soluble factors that enhance angio-
ment is required, in order to clean the wound’s genesis, decrease apoptosis, and/or modulate the
bed and stimulate the healing process. In severe immune response [33, 34]. Fat grafting has been
cases, surgical coverage becomes mandatory. largely used in chronic RD management: non-
Skin grafts represent a safe and easy-to-perform healing ulcers [35], radiation-induced skin fibro-
solution, but their use is limited. Radiated tissues sis [36], and radiation-induced joint contracture
present compromised vascularization even in [37] showed encouraging improvements after
peripheral areas that do not present clinical signs treatment.
20 Radiodermatitis: Prevention and Treatment 317
Fig. 20.1 Chronic ulcer of the leg in a patient suffering Fig. 20.2 After accurate wide surgical debridement, cov-
from sarcoma of the tibialis anterior muscle and under- erage was achieved with pedicled myocutaneous sural flap
went radiation therapy. Four years after, he presented with
chronic RD with non-healing ulceration
The exact pathogenic mechanism underlying
capsular contracture is still unknown, but it is
Regarding breast cancer patients, both mas- considered a multifactorial process, resulting
tectomies and implant-based reconstruction rates from human body reaction, biofilm activation,
presented constant increase in the last decades bacteremic seeding, or silicone exposure [41]. In
[38–40]. As a consequence, immediate and contrast with the numerous studies concerning
delayed complications caused by post-the RT effects on biological tissues, only a few
mastectomy radiotherapy are increasing as well. studies investigated the effect that ionizing radia-
Capsular contracture, infection, ulceration, and tion has on breast implants. The authors of the
implant exposure represent the radiation therapy- current session carried out multi-technique stud-
related complications that breast cancer-survival ies in order to characterize radiation-induced
patients have to face. Capsular contracture, in modifications in terms of surface morphology,
particular, represents a frequent adverse event of mechanical properties, and material chemistry in
radiation therapy, and it leads to breast distortion, breast implants that underwent standard and
pain, and unsatisfactory aesthetic appearance. hypofractionated radiotherapy protocols [42, 43].
318 D. Ribuffo et al.
Fig. 20.3 Female patient that underwent skin-sparing Fig. 20.5 Postoperative picture taken 2 months after sur-
mastectomy of the left breast, followed by radiation ther- gery: thanks to a wide radiated tissue dissection and an
apy. Two years after, she developed chronic RD with accurate selection of reliable recipient vessels, the DIEP
marked atrophy and telangiectasia. DIEP flap was sched- flap was transferred successfully
uled for an autologous delayed breast reconstruction, and
deep inferior epigastric perforators patency was assessed
with CT angiography
Key Point
It has been evidenced that ionizing radia-
tion may induce biomaterial alterations in
prosthetic materials, and they might play a
role in the development of breast capsular
contracture.
23. LENT SOMA scales for all anatomic sites. Int J breast reconstruction with implants. Eur Rev Med
Radiat Oncol Biol Phys. 1995;31:1049–1091. Pharmacol Sci. 2012;16(12):1729–34.
24. Euro PEP: radiodermatitis (radiation skin reac- 35. Mohan A, Singh S. Use of fat transfer to treat a
tions)—improving symptom management chronic, non-healing, post-radiation ulcer: a case
in cancer care through evidence based prac- study. J Wound Care. 2017;26(5):272–3.
tice. https://www.cancernurse.eu/documents/ 36. Borrelli MR, Shen AH, Lee GK, Momeni A, Longaker
EONSPEPRadiodermatitisEnglish.pdf. Accessed MT, Wan DC. Radiation-induced skin fibrosis:
May 2020. pathogenesis, current treatment options, and emerg-
25. Kitajima M, Mikami K, Noto Y, Itaki C, Fukushi ing therapeutics. Ann Plast Surg. 2019;83(4S Suppl
Y, Hirota Y, Mariya Y, Tsushima M, Kattou K, 1):S59–64.
Osanai T. Quantitative assessment of radioderma- 37. Borrelli MR, Diaz Deleon NM, Adem S, Patel RA,
titis through a non-invasive objective procedure Mascharak S, Shen AH, Irizarry D, Nguyen D,
in patients with breast cancer. Mol Clin Oncol. Momeni A, Longaker MT, Wan DC. Fat grafting res-
2020;12(1):89–93. cues radiation-induced joint contracture. Stem Cells.
26. Wong RK, Bensadoun RJ, Boers-Doets CB, Bryce 2020;38(3):382–9.
J, Chan A, Epstein JB, Eaby-Sandy B, Lacouture 38. Lo Torto F, Marcasciano M, Kaciulyte J, Redi
ME. Clinical practice guidelines for the preven- U, Barellini L, De Luca A, Perra A, Frattaroli
tion and treatment of acute and late radiation reac- JM, Cavalieri E, Di Taranto G, Greco M, Casella
tions from the MASCC Skin Toxicity Study Group. D. Prepectoral breast reconstruction with TiLoop®
Support Care Cancer. 2013;21(10):2933–48. Bra Pocket: a single center prospective study. Eur Rev
27. Nazarian RS, Lucey P, Franco L, Zouzias C, Med Pharmacol Sci. 2020;24(3):991–9.
Chennupati S, Kalnicki S, McLellan BN. Referral 39. Marcasciano M, Frattaroli J, Mori FLR, Lo Torto
practices to dermatologists for the treatment of F, Fioramonti P, Cavalieri E, Kaciulyte J, Greco M,
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28. Kremer T, Cordts T, Hirche C, Hernekamp F, Radu C, going breast reconstruction. Aesthet Plast Surg.
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Maxillofacial Surgery
21
Giuseppe Giudice and Erica Tedone Clemente
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 323
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_21
324 G. Giudice and E. T. Clemente
Table 21.1 Glasgow coma scale (GCS). It is based on laryngeal and pharyngeal reflex. For this rea-
three types of response to stimuli (ocular, verbal, motor) son, it is important to subluxate the mandible,
and is expressed synthetically with a number whose sum
indicates the patient’s neurological status and evolution.
force mouth opening, and remove any foreign
The index can vary from 3 (A1-B1-C1) deep coma to 15 bodies. If the presence of liquids is suspected,
(A4-B5-C1) awake and conscious patients the patient must be placed in a lateral decubi-
Behavior Response Score tus position.
Eye opening Spontaneously 4 • Retroposition of the tongue, caused by a
response To speech 3 hematoma of the floor of the mouth or, more
To pain 2
frequently, by a bifocal fracture involving
No response 1
Best verbal Oriented to time, place, and 5 both parasymphysis of the mandible that
response person 4 causes a posterior displacement of the chin
Confused 3 due to the loss of the anterior anchorage of the
Inappropriate words 2 genioglossus and geniohyoid muscles. The
Incomprehensible sounds 1
No response tongue must be raised, anteriorly pulled and
Best motor Obeys commands 6 anchored to the teeth or cheek using a suture
response Moves to localized pain 5 (in these cases, it is always useful to place a
Flexion withdrawal from 4 cannula of Mayo).
pain 3
Abnormal flexion 2
• Occlusion of the oropharynx by the soft palate
(decorticate) 1 due to back and inferior displacement of the
Abnormal extension maxilla in cases of Le Fort II–III fractures.
(decerebrate) Restoration of the airway patency can be
No response
achieved with a partial and forced manual
Minor brain injury, 13–15 points; moderate brain injury,
reduction of the fracture, positioning the index
9–12 points; severe brain injury, 3–8 points; deep coma or
death, 3 and middle fingers of one hand inside the oro-
pharynx, and pushing them posteriorly, with
the thumb on the upper incisors and the other
21.2.1 Primary Diagnostic- hand positioned on the forehead to stabilize
Therapeutic Approach the movement and exercise an opposite force;
then, the reduction maneuver will be achieved
21.2.1.1 Upper Airway Obstruction pulling forward and upward. This maneuver,
Obstruction of the upper airway requires imme- while not ensuring correct alignment of frac-
diate treatment at the site of the trauma. The tured segments, allows breathing restoration.
severity of this event is linked to a state of hypoxia
or hypercapnia which can cause “direct” brain When patency of the upper airways cannot be
damage due to neuronal suffering or an “indirect” achieved using these maneuvers, then we must
injury due to an increase in respiratory efforts rely on the endotracheal intubation.
which can cause brain swelling and intraparen-
chymal bleeding leading to an increase of the 21.2.1.2 Arrest of Bleeding
intracranial venous pressure [3]. In patients showing craniofacial traumas, hem-
The causes of mechanical respiratory insuffi- orrhages are due to skin wounds and/or lesions
ciency for patients affected by craniofacial trau- of vessels that run in the soft tissues or inside
mas can be due to: the bone channels. The bleeding wounds should
be treated using sterile gauzes soaked in saline.
• Oropharyngeal obstruction by liquid (vomit, In severe cases, the ligation of the facial artery
blood, saliva) or solid (mold, teeth, dentures, may be necessary. A very serious circumstance
bone fragments, foreign bodies). It is is the rupture of the internal maxillary artery,
aggravated, in unconscious patients, by the the terminal branch of the external carotid
loss of muscle tone and the absence of the artery, which runs into the pterygo-palatine
21 Maxillofacial Surgery 325
fossa. In this case, the external carotid ligation 21.2.3 Tertiary Diagnostic-
is necessary shortly after its origin from the Therapeutic Approach
common carotid.
Bleeding from the nasal fossae is much more “Multidisciplinary Center”
frequent for these patients for obvious anatomi-
• Treatment of soft tissues
cal reasons. Epistaxis can be mono- or bilateral
• Treatment of hard tissues
and is divided into:
• Isolated (squama, sinuses, roof, or supraor- • Exophthalmos, with difficult complete closure
bital margin) of the eye and consequent corneal exposure;
• Associated with fractures of other bones this clinical sign is characteristic of a dis-
(nose, orbit, ethmoid) placed fracture of the orbital roof. Pulsating
exophthalmos occurs due to transmitted brain
Due to its structure, the frontal bone is the pulsations.
most resistant bone of the splanchnocranium; a • Ptosis, due to paralysis of the levator palpe-
fracture at this level requires a force 4–5 times brae superioris muscle with obstruction of the
greater than the force required to produce a frac- movements of the levator and upper rectus
ture in the cheekbone or nasal bones. Such vio- muscles.
lent traumas can cause injuries to the noble • Diplopia, due to incarceration of the muscular
structures, protected by the frontal bone, located bellies between the fractured segments, or due
in the anterior cranial fossa (frontal brain lobes). to paralysis caused by an involvement of the
Fractures usually occur at the level of the loci third cranial nerve caused by external com-
minoris resistentiae, such as the roof of the orbit pression (hematoma, bone fragment) or by
and the frontal sinuses (up to 10% of all cranial direct damage.
fractures). In one third of the cases, the trauma • Superior orbital fissure syndrome: cluster of
causes a fracture only of the anterior wall of the signs and symptoms due to a fracture of the
sinuses; in the remaining two thirds of the cases, orbital roof up to the upper orbital fissure, pas-
there is a fracture of the posterior wall, and the sage channel of the III, IV, and VI cranial
frontonasal ducts are involved. These fractures nerve and the ophthalmic branch of the V cra-
must be suspected and promptly treated in order nial nerve. Orbital apex syndrome: due to the
to avoid relevant neurological complications (due involvement of the optic foramen, the passage
to the frequent involvement of the frontal lobes point of the optic nerve.
and ocular globes) [5].
The frontal bone is often involved in the con-
text of a trauma that also affects the nose and
orbits (fronto-naso-orbito-ethmoid fractures) [6, Pearls and Pitfalls
7]. Often, this kind of fracture is not diagnosed Superior orbital fissure syndrome:
and therefore erroneously treated as a simple
nasal fracture. Clinical examination must be thor- • Paralysis of the muscles innervated by
oughly carried out to assess the presence of sug- the oculomotor nerve: the levator pal-
gesting clinical signs that may be associated with pebrae with ptosis, the superior rectus,
those fractures of the frontal bone (Fig. 21.1). the inferior rectus, and the inferior
oblique
• Paralysis of the muscle innervated by
21.4.1 Clinical Presentation the trochlear nerve: the superior oblique
• Paralysis of the muscle innervated by
Clinically, the following can be observed: the abducens nerve: the lateral rectus
• Sensory deficit of the areas innervated
• Edema of the frontal and eyebrow region. by the ophthalmic branch of the trigemi-
• Bruising and/or conjunctival and eyelid hema- nal nerve: the eyebrow, the upper eyelid,
tomas, particularly in the presence of a frac- the glabella, and the homolateral frontal
ture of the orbital roof. skin
• Depressed areas, especially in the case of
fractures of the frontal sinuses or the supraor- Orbital apex syndrome: superior orbital
bital margin (uncommon finding due to gener- fissure syndrome + blindness
ally massive soft tissue edema).
21 Maxillofacial Surgery 327
Fig. 21.1 Pre- and postoperative CT scan showing multiples and comminuted fractures of the frontal bone and midface
fractures
examination, hiding the signs of bone interrup- • Pain, spontaneous or not, is the constant symp-
tion. Even diplopia, often present, may not tom; it can be exacerbated by palpation of the
manifest immediately after the trauma as intra- fractures and/or during swallowing movements.
and/or periorbital edema can support the ocular • Diplopia.
globe, keeping it in line for a few days. • Enophthalmos (blow-out fracture).
• Maxillary fractures • Exophthalmos (blow-in fracture).
Less frequent than O.M.Z.C. fractures, • Hypertelorism/telecanthus.
being the maxilla less exposed to traumatic • Depression of the zygomatic bone or arch.
insults, these fractures occur due to traumas of • Limitation of the opening of the mouth due to
particular intensity which are mainly exer- the interference between the coronoid process
cised in an anteroposterior direction. Rarely of the mandible and the posterior face of the
isolated (sports injuries) are more frequently depressed zygomatic arch.
associated with fractures of other districts. • Elongation and flattening of the face with
• Associated maxillo-orbital-malar-zygomatic depression of the nasal pyramid and of the
fractures zygomatic regions associated with the deforma-
As a result of a high or medium energy, the tion of the orbital region (flat face) in the event
maxillo-orbital-malar-zygomatic fractures are of a craniofacial disjunction (elongated face).
often associated with trauma of: • Malocclusion (e.g., post-traumatic open bite).
–– The anterior cranial fossa (due to an injury • Intraoral pathological mobility due to fracture
to the cribriform plate of the ethmoid or the of one or more portions of the upper alveolar
anterior and/or posterior wall of the frontal process.
sinus); • Diastema of the central incisors for fracture of
–– The middle cranial fossa with lesions of the the palate.
petrous part of the temporal bone (associ- • Coronal lesions associated with dental
ated with paralysis of the facial nerve) avulsions.
–– The fronto-nose-orbital region • Nasal deformities: “C” or “S” deformity of the
–– The mandible nasal pyramid, saddle nose, and twisted nose.
• Crepitus due to rubbing of bone fragments
These fractures, usually multiple and commi- and/or presence of emphysematous bubbles in
nuted, are often very unstable and characterized soft tissues.
by a remarkable hypermobility of the bone seg- • Liquorrhea.
ments followed by a severe deformity of the skull
and face. Instrumental diagnosis can be provided by CT
scan, with axial, coronal, and sagittal reconstruc-
tions and, if possible, with three-dimensional recon-
21.5.1 Clinical Presentation structions. CT scan replaced traditional radiography
for a more complete and accurate diagnosis.
Clinically, the following can be noted:
Fig. 21.2 Le Fort I fracture associated with a zygomatic fracture and NOE fracture. The reconstruction of the but-
tresses is shown in the postoperative X-ray
Sometimes for complex, comminuted, or multi- In cases of fractures of the maxilla, incision of
fragmentary lesions involving other bone struc- the upper vestibular fornix allows to completely
tures of the middle third, it is necessary to use open expose the buttresses and to reduce the fractures
reduction techniques through pre-existing wounds that are then synthesized using internal rigid fixa-
or coronal incisions. The fractures will be then tion systems. Other useful surgical accesses are
synthesized using “X”- or “Y”-shaped micro- transconjunctival, subciliary incision, supraorbital
plates. Regardless of the technique used and the incision (to access the “key point”), and coronal
access mode, after the reduction, an anterior nasal incision in cases where a large exposure is needed.
packing is applied for 3 days and an external The goals of the orbital fracture treatment are
splinting for about 10 days. The surgical protocol not only to free incarcerated soft tissue but, mainly,
that aims to an accurate repositioning of all bone to restore the anatomy and volume of the internal
structures and the restoration of the buttresses and orbit and to prevent long-term damages like per-
vertical, sagittal, and transverse dimensions fol- manent paresthesia and enophthalmos (Fig. 21.3).
lowing a sequential order is the “key” to success in The surgical approach and the material chosen to
treating these fractures (Fig. 21.2). reconstruct the orbital floor should aim to a minor
morbidity and greater stability for the patient.
Late Complications
• Enophthalmos.
• Diplopia.
• Telecanthus.
• Depression of the frontal bone (if involved in
a fracture that affects the middle third of the
face).
• Nasal deformities.
• Depression of the zygomatic arch that can
cause limitation to the movements of the
mandible.
• Deformity of the zygomatic bone due to
impaired reduction of a fracture of the
O.M.Z.C. can cause dystopia of the ocular
globe.
• Impaired sensitivity due to damage to the
nerves that pass through the zygomatic body.
• Sinus infections of the frontal, ethmoidal, and
maxillary sinuses.
• Obstruction of the nasal cavities due to devia-
tion of the nasal septum following a poorly
consolidated fracture.
Fig. 21.3 CT scan in a coronal plane reconstruction, • Malocclusion.
showing an orbital floor fracture. Arrow points to the infe- • Lesions of the tear apparatus.
rior rectus muscle incarcerated between the two bone
• Lagophthalmos due to scar retraction of post-
fragments, causing diplopia
traumatic or surgical wounds (marginal or
subciliary incision) or fractures of the orbital
21.5.3 Complications margin or the orbital floor, badly treated or
untreated.
Early Complications
• Ocular globe injury: even if it is not frequent, Pearls and Pitfalls
it can heavily affect the patient’s prognosis Remember that three nerves pass through
quoad valetudinem, leading to serious ana- the zygomatic bone:
tomical and/or functional permanent damage.
Ocular globe trauma is distinguished in: • Infraorbital nerve
–– Closed globe trauma: a clinical condition • Zygomaticotemporal nerve
characterized by an absence of wound • Zygomaticofacial nerve
(contusion) or a partial wound of the eye-
wall (lamellar laceration).
–– Open globe trauma: the cornea and/or
sclera presents a full-thickness wound. 21.6 Fractures of the Lower Third
• Injury of the optic nerve: reversible if due to
compressions (hematomas, bone fragments) The position, protrusion, and anatomical configu-
or irreversible if due to direct complete or ration of the mandible make this bone particu-
incomplete injury of the nerve caused by a larly exposed to fractures. Due to the
sharp object or a bullet or following fractures ever-increasing number of road accidents, the
involving the optic foramen. fracture of the mandible has become one of the
• Brain injury. most frequently encountered pathologies in
332 G. Giudice and E. T. Clemente
trauma centers around the world. From the epide- mental foramen constitutes a weak point and
miological point of view, in order of frequency, in therefore a frequent fracture site; the mandible is
addition to road accidents, they can be due to thin at the level of the angles, particularly exposed
trauma, falls, assaults, sports injuries, gunshots to fracture especially if a third molar is included,
inflicted by others or self-inflicted, or difficult contributing to the fragility of the area; the con-
tooth extractions. dyle, particularly at the neck, is the weakest point
The mandible as a whole is a very robust and (Tables 21.3 and 21.4). This is due to the neces-
resistant bone, but it does have some “loci mino- sity to protect the brain, at the middle cranial
ris resistentiae.” The body is mainly made of fossa, from the deleterious effects of the trau-
dense cortical bone with a small amount of can- matic energy transmitted by the condyle during a
cellous bone; the presence of a canal through the trauma. In fact, while condylar fractures repre-
thickness of the body ending at the level of the sent over 35% of all mandibular fractures, only
Table 21.4 Classification of condylar fractures synthesis of the fracture. Other conditions, local
Criteria Characteristics and systemic, predisposing to the fracture of the
Site of • Intracapsular fracture: direct mandible are:
fracture involvement of the TMJ can result in
ankylosis • Osteomalacia
• Extracapsular fracture: there is the
displacement of a more voluminous • Metastasis
skeletal fragment, and morpho-functional • Infection
alterations will be more evident, since the • “Fragilitas ossium”
action of the external pterygoid muscle • Benign/malignant tumors
causes an anteromedial dislocation of the
condylar fragment • Cysts
Type of • Not displaced fracture (no movement of • Osteomyelitis
fracture the fractured bone) • Drugs (e.g., bisphosphonates)
• Displaced fractures (medially or laterally)
In case of condyle fractures [9] (Fig. 21.5), the
alteration of the physiological relationship
between the condyle and the glenoid fossa has an
impact on the structure of the stomatognathic
system. In case of a patient that is still in growing
age, in additioncondylar fractures to the struc-
tural damage resulting from the trauma, clinical
pictures may arise resulting from a deficit of
mandibular growth, which can affect the develop-
ment of the lower and middle third of the facial
skeleton. In the case of an adult patient, great
importance will be given to the direct conse-
quences of structural damage.
Fig. 21.4 CT scan showing an unfavorable mandibular Clinically the following can be observed:
fracture
• Malocclusion: any condition characterized by
15 cases of intracranial dislocation of the man- alteration of normal dental occlusion. It can be
dibular condyle have been described in very evident presenting itself with clinical
literature. scenarios, or it can simply be a subjective
It is interesting to note how total or partial symptom of the patient, who reports that he
edentulism constitutes a further weakening fac- “does not close his mouth normally, as usual.”
tor. In fact, with tooth loss, the alveolar bone A post-traumatic open bite with mandibular
changes, becoming atrophic; this is the reason retrusion, with patient’s inability to close his
why this bone, in an edentulous patient, is par- mouth, can result from a bilateral fracture of
ticularly exposed to the risk of fractures, just as the mandibular body, with an unfavorable
the fracture is more frequent at the level of eden- direction of the fracture, since the suprahyoid
tulous areas in a mandible that has only a partial muscles exert a downward pulling force of the
dentition, rather than at the level of areas best mandibular segment placed medially at the
supported by adequate dental structures. fracture site. It can also occur when the condy-
Furthermore, the lack of dental elements repre- lar fracture is bilateral in case of a displaced
sents an obstacle to the subsequent reduction and bicondylar fracture, due to the displacement
334 G. Giudice and E. T. Clemente
Fig. 21.5 CT scan in a coronal reconstruction (left) and 3D reconstruction (right), showing a condylar fracture with a
medial displacement
of the two condyles, which causes a reduction • Sialorrhea: the patient avoids any swallowing
of the posterior vertical height of the two man- movement, which causes severe pain; salivary
dibular rami (due to the action of the ptery- secretion is also increased due to painful stim-
goid, temporal, and masseter muscles on the ulation of the salivary glands.
fractured segments). In a monocondylar frac- • Pain spontaneous or stimulated by palpation.
ture, structural alteration and muscle dysfunc- • Coronal lesions and/or dental avulsions.
tion manifest with an open bite contralateral to
the lesion, with an ipsilateral cross-bite and a Instrumental diagnosis:
lateral-deviation of the lower incisor line
toward the side of the lesion due to the unilat- –– Orthopantomography (OPT) is the first radio-
eral reduction of the vertical height of the graphic assessment to be performed as it
mandibular ramus. From a functional point of allows identification of the site and number of
view, there is a functional deficit of the exter- fractures and vertical displacement of the frac-
nal pterygoid muscle on the side of the frac- tured segments. This examination provides a
ture which is at the origin of the mandibular bidimensional overview of the mandible.
lateral-deviation and a deficit of the contralat- –– CT scan, with coronal and sagittal reconstruc-
eral lateral movement. tions and, if possible, with three-dimensional
• Functional limitation in the opening and clos- reconstructions, provides a more accurate diag-
ing movements of the mouth. nosis, especially if the condyle is involved. It is
• Edema important to underline that the most accurate
• Bruising/hematoma (which can extend to the exam for the temporomandibular joint (TMJ) and
floor of the mouth and/or neck due to lesion of its delicate fibrocartilaginous components is the
the facial artery). MRI, but is not performed in emergency [10].
• Deformity of the face: in addition to the mas-
sive swelling of the soft tissues due to altera-
tion of the vertical and sagittal dimensions. 21.6.2 Surgical Treatment
• Pathological mobility of bone segments due to
fracture of one or more portions of the alveo- The treatment of a mandibular fracture must aim
lar process. to achieve three goals:
• Crepitus.
• Fetor oris, caused by the patient’s inability to 1. Normocclusion
swallow, is an indication of an intraoral 2. Chewing functionality
hemorrhage. 3. Facial eurythmy
21 Maxillofacial Surgery 335
Treatment of mandibular fractures can be con- and screws of various shapes and sizes. An inter-
servative or surgical. maxillary blockage can, in certain cases, be a
phase of the surgical treatment, because it allows
21.6.2.1 Conservative Treatment an excellent intraoperative dental intercuspation
It is indicated in the case of fractures character- which promotes good alignment of bone seg-
ized by a modest displacement of the bone seg- ments in comminuted fractures.
ments and of fractures of the neck of the condyle.
The treatment consists of an intermaxillary fixa-
tion performed after restoring a maximum inter- Pearls and Pitfalls
cuspation and therefore an acceptable occlusion. Remember: when a condyle is surgically
It must be kept in place for 2–3 weeks. An inter- treated, the approach is through the parotid
maxillary fixation can also be performed using gland, and it can cause temporary or per-
orthodontic devices (brackets) and elastic bands manent facial nerve damage.
to connect them. An alternative is the intraosse-
ous intermaxillary fixation using 4–6 bicortical
The use of internal rigid fixation systems is
screws, generally applied under local anesthesia
also particularly suitable in the cases of:
or under general anesthesia if needed to treat
associated fractures. The benefits of this tech-
• Fracture of the mandible in partially or totally
nique, compared to the external intermaxillary
edentulous patients, which are not good candi-
fixation, are:
dates for intermaxillary fixation
• Fractures of the mandibular angle with dis-
• Speed and ease of application
placement of the segments
• Greater acceptance by patients
• Absolute contraindications for the intermaxil-
• Reduction of trauma to the oral mucosa and
lary fixation (respiratory failure, risk for ab-
gums
ingestis pneumonia)
• Reduction of the risk of skin puncture with
reduction of the risk of transmission between
The purpose of osteosynthesis using internal
patients and surgeon of viral diseases (HBV,
rigid fixation is to achieve an effective reduction
HCV, and HIV)
of the fracture, avoiding a prolonged postopera-
• Ease and less painful removal
tive intermaxillary fixation which can lead to:
Fig. 21.6 CT scan in a 3D reconstruction showing preoperative and postoperative multiple mandibular fracture of the
left parasymphysis, left ramus, left O.M.Z.C. treated with internal fixation
21 Maxillofacial Surgery 337
21.6.3 Complications
thought to be from increased intraorbital
Early Complications pressure, which causes the orbital bones
to break at their weakest point.
• Obstruction of the upper airways, due to ret- • Mandibular fractures are among the
roposition of the tongue. most common traumatic injuries of the
• Subcutaneous hematoma, when the fracture of maxillofacial region which jeopardize
the mandible is accompanied by a massive both aesthetic and function.
bleeding, the blood vessels must be ligated or • The occlusion, form, and function
clamped. A hematoma at the level of the floor should all be considered in the manage-
of the mouth can lead to obstruction of the ment of mandibular fracture with the
passage of air at the level of the oropharynx; internal fixation as the most common
therefore, it might be necessary to perform an surgical treatment.
emergency tracheotomy.
• Emphysema: the air that has entered the soft
tissue can cause respiratory obstruction.
Late Complications
References
Further Reading
https://www.sicmf.org/libri/trattato-patologia-chirurgia-
maxillo-facciale
Perry M, Holmes S (eds.) Atlas of operative maxillofa-
cial trauma surgery, 1. https://doi.org/10.1007/978-1-
4471-2855-7_1. London: © Springer-Verlag; 2014.
Part lV
Plastic Surgery in Cancer Therapy
Plastic Surgery for Skin Cancer
22
Michelangelo Vestita, Pasquale Tedeschi,
and Domenico Bonamonte
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 341
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_22
342 M. Vestita et al.
22.2 Keratoacanthoma
tumor’s scalloped outer border has lost its infil- Intermittent extreme sun exposure as identified
trative character and is reduced to a thin rim of by previous sunburns, radiation therapy, BCC’s
keratinizing cells lining a large crater filled with positive family history, immunosuppression, fair
keratin. complexion, particularly red hair, easy sunburn-
It may not always be possible to differentiate a ing (skin types I or II), and childhood blistering
benign-behaving keratoacanthoma versus a sunburns are risk factors for BCC development.
potentially aggressive SCC. Even if one sees the Indoor tanning is a considerable risk factor for
classic histological characteristics of keratoacan- early BCC. Actinic elastosis and wrinkling are
thoma, the diagnosis of SCC should be consid- not risk factors for BCC’s growth. These results
ered if the lesion is not behaving as expected. indicate that the process by which BCC is caused
by UV radiation is not strictly related to the total
amount of UV obtained. Unlike actinic keratoses
22.5 Treatment and SCCs, it’s more difficult to demonstrate pre-
vention with regular use of sunscreens. Having
had a BCC, the risk for a subsequent BCC is high:
Tips and Tricks 44 percent over the next 3 years.
Even though keratoacanthomas involute
spontaneously, it is difficult to predict how
long it will take. More importantly, it is not 22.6.1 Clinical Features
always possible to clinically exclude
SCC. Hence, in most cases, excisional There are many clinical BCC morphologies.
biopsy of the typical keratoacanthoma Medical diagnosis relies on the clinician being
should be considered. able to recognize the various forms that BCC can
take.
The classic or nodular BCC makes up 50–80%
of all BCCs. Nodular BCC consists of one or a
Nonsurgical treatment can also be considered few thin, semi-translucent papules that form
for maintaining function or enhancing cosmetic around a central depression that may or may not
results in some locations. Intralesional 5-FU, be ulcerated, crusted, and bleeded (Fig. 22.2).
bleomycin, or methotrexate may be efficient. There is a typical rolled border to the edge of
Low-dose systemic methotrexate can be consid- larger lesions. The path of telangiectases is
ered when there are multiple lesions, and no through the lesion. When development continues,
contraindication is present. Radiation therapy
crusting occurs over a central erosion or ulcer,
can also be used on giant keratoacanthomas when and bleeding happens when the crust is broken or
surgical excision is not possible. pulled off, and the ulcer becomes visible. The
ulcer over time becomes chronic and faces a pro-
gressive enlargement (Fig. 22.3). The lesions are
asymptomatic, and the only problem experienced
22.6 Basal Cell Carcinoma is bleeding. The lesions are found most frequently
on the face and particularly on the nose (25–
30%). Forehead, ears, periocular areas, and
Key Point cheeks are also often involved.
Basal cell carcinoma (BCC) is the most Morpheaform BCC is a white sclerotic plaque,
prevalent cancer associated with moderate mostly occurring on the head and neck.
sun exposure worldwide, especially in Ulceration, a pearly rolled line, and typically no
countries with a predominantly white, fair- crusting are typical features. Telangiectasia is
skinned population. variably present. Hence, the lesion is often for
some time missed or misdiagnosed. The differen-
344 M. Vestita et al.
Key Point
The second most common type of skin can-
cer is squamous cell carcinoma (SCC).
Chronic, long-term exposure to sunlight is
the main risk factor, and areas with such
exposure (face, scalp, back, dorsal hands)
are preferred locations. Immunosuppression
greatly increases the risk of SCC develop-
ment, approx. 80-fold to 200-fold among
organ transplant recipients.
Key Point
Lesions at high risk of recurrence and
metastasis are those of the lip, ear, or ano-
genital skin; those developing in scars or
irradiation sites; those of 2 cm or more in
diameter; those of more than 4 mm thick-
Fig. 22.5 Squamous cell carcinoma on actinic cheilitis ness; those with low histological differen-
tiation or perineural invasion; and those of
patients with organ transplantation or
associated with a metastatic rate of 4% and hematological malignancy. Such patients
>6 mm associated with a metastatic rate of 16%. may be considered for a more intensive sur-
Immunosuppression, location on the ear, and gical approach and adjuvant radiotherapy
increased horizontal size all increase metastasis treatment. Careful attention should be pro-
risk by double- to fourfold. Desmoplasia and vided to regional lymph nodes which drain
thickness also increase the risk of local recur- the SCC site.
rence. Other types of neoplasms, such as mela-
noma, need to be excluded in tumors which are
poorly differentiated. Weak prognostic character-
istics are the identification of perineural or vascu- 22.8.4 Treatment
lar invasion and recurrence.
The key treatment for cutaneous SCC is surgical
removal. Pembrolizumab can play a role in the
22.8.3 Differential Diagnosis treatment in advanced illness. For patients for
whom traditional therapies are not feasible alter-
For most cases, the separation of SCC from natives, electrochemotherapy has been used as
keratoacanthoma is of relative importance, palliative therapy, as with BCC. Organ transplant
because on most of these lesions, surgical exci- recipients should be informed about sun safety
sion is performed. The rapid growth and pres- and skin cancer risk and should have frequent
ence of a rolled border with a central keratotic skin exams.
348 M. Vestita et al.
22.10 W
ound Healing, Flaps,
and Grafts
22.10.1 H
ealing by Second
Key Point Intention
Fusiform excision is the common tech-
nique used to treat skin cancers. The basic In selected clinical settings, wound healing by
concept of the fusiform ellipse is the exci- second intention is excellent, such as superficial
sion of a specimen which is aligned along wounds in concave areas, partial-thickness
skin tension lines (Fig. 22.6, Video 22.1). wounds involving lip mucosa, or other clinical
conditions, such as elderly or vulnerable patients
with reduced cosmetic issues. Wound treatment
is simple, and there are few postoperative
Non-melanoma skin cancers (NMSCs): restrictions.
Squamous cell carcinoma.
To fit the final scar better with skin tension
lines, the ellipse may be bent in a crescentic or 22.10.2 Dermal Matrices
“lazy S” shape. If the procedure is done with the
appropriate proportions (usually a length/width Acellular dermal matrices are a class of biologi-
ratio of 3:1) and an angle of 30° at each end, cal and/or synthetic scaffolds used to replace
standing cutaneous cones are normally avoided at deficient or missing sub-epidermal soft tissues.
the two ends of the excision. Standing cutaneous In clinical practice, they are often used to substi-
cones reflect excess bunching of tissue at the tute for dermis and soft tissues after full-thickness
poles of a skin closure and should be “stitched removal of wide cutaneous malignancies in sites
out” or excised with triangulation or M-plasty, if not amenable to immediate reconstruction (Video
necessary. Undermining, using sharp or blunt 22.2). They are usually left in place to integrate
22 Plastic Surgery for Skin Cancer 349
and revascularize for 2–3 weeks and are then 22.10.3.1 Advancement Flap
covered with a split-thickness skin graft. (Fig. 22.7)
An advancement flap moves mostly in one linear
direction. The classic advancement flap involves
22.10.3 Flaps the formation of a rectangular pedicle, slipping
over the primary surgical defect to place. The
main suture carries the flap forward and covers
Key Point the primary defect. Tissue redundancies can be
Local skin flaps are geometric tissue seg- removed via triangulation (Burow triangles) at
ments surrounding a skin defect which are the base of the flap. Survival of the distal tip of
advanced, rotated, or transposed to close a the flap is based on the base blood supply, and
wound. The benefits of flaps include thus a maximum length/width ratio of 3:1 should
improved approximation of skin texture be planned.
and color, concealment of incision lines, If insufficient movement with a single advance
redirection of tension vectors, and preser- flap is obtained, a bilateral advancement (O–H)
vation of exposed cartilage and bone. can be used, so that each flap advances to cover
Survival of flaps is dependent on pre- half the defect. This can be used in repairs to the
serving random blood supply around the eyebrow or helical surface. Single-arm advance
pedicle. Consideration of both the primary flaps (O–L) and bilateral single-arm advance
flap movement (actual flap movement flaps (O–T) are similar to classic advance flaps,
through defect) and secondary movement except that only one incision is made and the
(movement of surrounding tissue in standing cone is removed through triangulation.
response to flap movement) is important Such flaps have the advantage of a wider pedicle
when designing the repair. providing blood supply and allowing a linear por-
tion of the flap to be concealed for better cos-
metic outcome in existing wrinkling.
350 M. Vestita et al.
The pedicle island flap (or “V–Y flap”) is a vascular pedicle. The bilateral variation is known
special variant of an advance flap. For its blood as the bilateral rotation flap (O–Z).
supply, this flap is dependent on a subcutaneous
vascular pedicle and has all the epidermal con- 22.10.3.3 Transposition Flaps
nections severed by incisions. (Fig. 22.9, Video 22.3)
The best cosmetic results are obtained when it In the case of the transposition flap, the flap is
is possible to conceal at least one of the incision transposed over intervening tissue and sutured into
lines inside a defined wrinkling or anatomic the primary defect. The tension vector is distrib-
boundary. uted through the secondary defect closure (area
originally occupied by flap). This type of flap is
22.10.3.2 Rotation Flap (Fig. 22.8) especially useful for defects which are adjacent to
Conceptually, the rotation flap can be considered free anatomical margins. The key suture closes the
a variation of the advancement flap, in that it secondary defect, and the flap is then lifted and
slides into position in a similar way, albeit in an transposed into position over the primary defect.
arcuate manner. Tension vectors from this pulling That flap’s prototype is the rhombic flap. Other
motion are directed along the rotation arc. The examples include bilobed flaps, nasolabial/melola-
flap has the advantage of strong survival, thanks bial flaps, banner flap, and the Z-plasty.
to the big pedicle and the ability to recruit skin The choice of a particular type of flap involves
from a long distance. A back cut can be used to multiple factors, including location of defect, avail-
minimize critical restriction and provide greater ability of tissue movement, surrounding structures,
mobility of the tissue, but this may weaken the effects of tissue movement, and blood supply.
22 Plastic Surgery for Skin Cancer 351
Key Point
A graft is by definition completely excised
from the donor site and devitalized (no
inherent blood supply). Success depends
on reattaching the vascular supply from the
defect to the graft. A possible drawback is
the lack of color and texture fit depending
on the distant donor position of the grafts.
Fig. 22.10 Harvest of split-thickness skin graft with a
dermatome
352 M. Vestita et al.
1
b
2
4
d
354 M. Vestita et al.
Skin Surgery 24. Adams DC, Ramsey ML. Grafts in dermatologic sur-
gery. Dermatol Surg. 2005;31:1055.
25. Blake BP, et al. Transposition flaps. Dermatol Surg.
16. Lawrence CM. An introduction to dermatological sur-
2015;41:S255.
gery. 2nd ed. St. Louis: Mosby; 2002.
26. Donaldson MR, Coldiron BM. Scars after second
17. Robinson JK, et al. Surgery of the skin: procedural der-
intention healing. Facial Plast Surg. 2012;28:497.
matology. 3rd ed. Philadelphia: Elsevier Mosby; 2015.
27. Lam TK, et al. Secondary intention healing and purse-
18. Epstein E, Epstein E Jr, editors. Skin Surgery. 5th ed.
string closures. Dermatol Surg. 2015;41:S178.
Springfield: Thomas; 1982.
28. Sobanko JF. Optimizing design and execution of
19. Telfer NR, Moy RL. Wound care after office proce-
linear reconstructions on the face. Dermatol Surg.
dures. J Dermatol Surg Oncol. 1993;19:722–31.
2015;41:S216.
20. Zitelli JA. Wound healing by secondary intention. J
29. National Comprehensive Cancer Network. Clinical
Am Acad Dermatol. 1983;9:407–15.
practice guidelines in oncology: basal cell and squa-
21. Rohrer TE, et al. Flaps and grafts in dermatologic sur-
mous cell skin cancers. Version 1. 2005. http://www.
gery. Philadelphia: Elsevier; 2007.
nccn.org/professionals/physician_gls/PDF/nmsc.pdf.
22. Roenigk RK, Zalla MJ. Full-thickness grafts. In:
Accessed 8 Aug 2005.
Robinson JK, Arndt KA, LeBoit PE, Wintroub BU,
30. Drake LA, et al. Guidelines of care for Mohs micro-
editors. Atlas of cutaneous surgery. Philadelphia:
graphic surgery. J Am Acad Dermatol. 1995;33(2 pt
Saunders; 1996.
1):271–8.
23. Brodland DG, et al. The history and evolution of Mohs
micrographic surgery. Dermatol Surg. 2000;26:303–7.
Plastic Surgery in Melanoma
Patients
23
Eleonora Nacchiero and Fabio Robusto
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 357
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_23
358 E. Nacchiero and F. Robusto
vival of these patients. On the other hand, these tion with the p16 protein, with a consequent
new expensive pharmacologic treatments have deregulation of the cell cycle (a mutation of
reached considerable costs in melanoma manage- the gene has been described in a few families
ment; moreover, as incidence rises, in the next of subjects affected by MM).
decades, costs of direct and indirect care are pro-
jected to concurrently rise. Currently, epidemio- Individuals with a mutation in one of these
logical studies try to better stratify populations at genes may have up to a 67% or 74% lifetime risk
risk and to implement population-based preven- to develop a melanoma, respectively, and they may
tion strategies. also present multiple dysplastic or atypical nevi.
Nodular melanoma (Fig. 23.3): it is the nevus, spitzoid melanomas, and MM devel-
second most common type of MM. It is oping in brown birthmarks or in atypical or
characterized by not having a radial growth dysplastic moles.
phase, but it progresses rapidly as a verti- Nevoid melanoma: a rare variant of
cally growing tumor in a few months. It MM characterized by morphologic fea-
typically presents blue to black nodules, tures of nevus.
although it can sometimes be pink or red in Persistent melanoma: the term recur-
color. These lesions also may have ulcer- rent melanoma has been abused, defining
ation and bleeding. melanomas that returned after their visible
Lentigo maligna: it appears usually as a portion has been excised, and for both local
large lesion that can occur in elderly and distant metastasis.
patients with heavily sun-damaged skin. It
begins as an irregularly shaped macule that
slowly grows to form a larger spot. In situ
forms can slowly grow in 5–15 years before
becoming invasive. A typical sign of inva-
sive changes is the formation of papules
arising on the area of the lesion.
Acral lentiginous melanoma
(Fig. 23.4): although it is equally frequent
in all races, it represents the most common
variant of MM in people with dark skin. It
typically arises on the digits (frequently
under nails), on the palms, and on the plan-
tar aspects of the feet. In case of subungueal
lesions, the differential diagnosis between
melanoma and post-traumatic hematoma
should be taken into account.
Desmoplastic and desmoplastic neuro-
tropic melanoma: it is a rare form of MM in
which the malignant cells within the dermis
are surrounded by fibrous tissue. Desmoplastic Fig. 23.2 Superficial spreading melanoma on the chest
wall
melanoma often involves nerve fibers, when
it is called neurotropic melanoma.
Melanoma arising from blue nevus:
melanomas arising in association with or
mimicking a blue nevi are a rare and het-
erogeneous group of melanomas.
Melanoma arising on a giant congeni-
tal nevus: giant congenital nevus is found
in 0.1% of live born infants. If present, the
lesion has a chance of about 6% to develop
into malignant melanoma.
Melanoma of childhood: childhood
melanoma usually refers to melanoma
diagnosed in individuals under the age of
18 years. In this category are classified
congenital melanomas, malignant blue
Fig. 23.3 Nodular melanoma on the shoulder
23 Plastic Surgery in Melanoma Patients 361
Key Point
Anatomically, superficial spreading MMs Prognostic Factors for Primary Lesion
show an initial radial growth phase within the Clark’s Level: it is a staging system,
epidermis and sometimes within the papillary which describes the level of anatomical
dermis, which may be followed by a vertical invasion of the MM in the skin. Level of
growth phase with deeper extension, while, in anatomical involvement is assessed in 5°:
nodular MM, the radial growth phase is absent or
• Level 1: lesion affects only the epider-
mis (in situ melanoma).
• Level 2: lesion affects the papillary der-
mis, spearing the papillary-reticular der-
mal interface.
• Level 3: lesion fills and expands the
papillary dermis, but it does not pene-
trate the reticular dermis.
• Level 4: lesion invades the reticular
dermis.
• Level 5: lesion affects also the subcuta-
neous tissue.
Fig. 23.6 Single stage procedure for the surgical treatment of a wide melanoma on the face
Key Point
Fig. 23.7 Melanoma with a regression area Margins of Wide Excision
In situ melanoma: 0.5 cm
Breslow’s depth ≤ 2 mm: 1 cm
Breslow’s depth > 2 mm: 2 cm
Key Point
Indications for SLNB
Breslow’s depth: a primary lesion
thickness > 0.8 mm Fig. 23.9 Preoperative marking of 3 sentinel nodes in a
Clark’s level: Clark’s level 4–5 malanoma on zygomatic region
Regression
Ulceration
High mitotic rate: ≥1 mitosis/mm3 the sentinel lymph node and the afferent lym-
Vertical growth phase phatic collector are isolated. Sometimes, lym-
Age: in young subjects, SLNB is always phoscintigraphic features can reveal the
recommended identification of more than one sentinel node
(Fig. 23.9): in these cases, all the marked lymph
nodes must be surgically removed. Usually, these
multiple sites occur in MM of the midline, and in
Preoperative lymphoscintigraphy provides these cases, two first lymphatic drainage path-
accurate information about lymphatic drainage ways can lead to two different first sentinel lymph
patterns, allowing a less invasive surgical proce- nodes from the initial tumor site.
dure through a direct incision over the node, Complications related to surgery are rare and
based on the images and probe counts. To date, usually not associated with significant morbidity.
lymphoscintigraphy is carried out using techne- Usually, they are local, and the most frequents
tium 99 m-nanocolloid human serum albumin are wound dehiscence and infection, seroma,
injected closely around the primary lesion or hematoma, lymphedema, and lymphocele; others
around the scar of the previous excision. The use more important but rare associated complications
of ultrahigh-resolution collimators is recom- are nerve injury and thrombophlebitis, deep vein
mended to imagine all the territories between the thrombosis, and hemorrhage. SLNB is the gold-
primary melanoma site and the recognized drain- standard procedure to assess lymphatic involve-
ing node field or fields. Acquisition of static and ment in MM because of its high diagnostic
dynamic images after the radiolabeled colloid sensitivity; use of CT, US, PET, or other imaging
injection and then after every lymph node visual- procedure has no similar sensitivity in the detec-
ization is important to be sure that all sentinel tion of lymph node metastases.
nodes were marked. The surgical procedure is In some anatomical sites or in patients with
simple and safe: a handheld gamma probe is used wide primary lesions located in areas with an aes-
during surgery to guide sentinel lymph node thetic or functional importance, execution of
detection; then, through a minimal skin incision, SLNB is more complex and less accurate. This is
366 E. Nacchiero and F. Robusto
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 371
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_24
372 T. Wright et al.
tures, then they are classified as pleomorphic ous radiotherapy and are commonly seen in the
dermal sarcomas. Local recurrence is common breast.
but they rarely metastasize. Malignant peripheral nerve sheath tumours
Tenosynovial giant cell tumour is a benign (also known as neurofibrosarcomas) arise in the
tumour of the synovium and may be localized or connective tissue around the nerve and may
diffuse (previously known as pigmented villon- therefore give rise to neurological symptoms
odular synovitis, PVNS). Complete excision is associated with that nerve. Around half of cases
recommended, but recurrences are common. are associated with a diagnosis of neurofibroma-
tosis type 1.
24.3.3 Sarcomas
24.4 Diagnosing Sarcoma
Malignant soft tissue tumours are known as sar-
comas. They are invasive and may metastasise Multidisciplinary meetings (MDTs) are central to
distantly via a haematogenous route or, less com- the management of sarcoma patients and are con-
monly in certain sub-types, to regional lymph sidered gold standard in cancer care. Introduced
nodes. to the NHS in 1995, MDTs improve overall
Liposarcomas are soft fatty tumours that can patient outcome by reducing variation in access
occur anywhere in the body. to services and allowing for better continuation
Fibrosarcomas have a variety of sub-types, of care. The National Institute of Healthcare
but their cells are known as histiocytes or fibro- Excellence (NICE) recommends all patients in
cytes and are most commonly diagnosed in the the UK with a suspected soft tissue sarcoma are
limbs. managed within a sarcoma MDT [1].
Undifferentiated pleomorphic sarcoma is a In these weekly meetings, a wide range of
high-grade fibroblastic subtype that was previ- health professionals come together to discuss
ously known as malignant fibrous histiocytoma. each patient and formulate an agreed manage-
Leiomyosarcomas develop from smooth ment plan. Sarcoma MDTs will usually consist of
muscle cells and are the most common soft tissue oncologists, surgeons, radiologists, pathologists,
sarcoma. They may arise anywhere in the body as specialist nurses and physiotherapists. Surgeons
smooth muscle forms the walls of blood vessels from multiple sub-specialties (orthopaedics, gen-
and many other organs. They may also arise eral surgery, urology, thoracics) may be involved
within the uterus. depending on the site of the sarcoma. In the UK,
Rhabdosarcoma are less common and are it is generally plastic and reconstructive surgeons
derived from striated muscle cells. They are that lead the surgical MDT, due to their knowl-
aggressive and more commonly found in children edge of anatomy and reconstructive options that
and younger adults, depending on the subtype. can guide what is feasible for each patient and
Synovial sarcoma is a less common variety, tailor treatment according to needs.
which is more commonly found associated with
large joints, is usually high grade and can metas-
tasize via the lymphatics. 24.5 Referral Pathway
Epithelioid sarcoma is another variety that is for Suspected Sarcoma
associated with a young adult age group, is usu-
ally high grade and is uncommon in that may Soft tissue masses are common in the population,
spread via the lymphatics. and fortunately, most lesions are benign. A diag-
Angiosarcomas are derived from blood or nosis of sarcoma should be suspected in anyone
lymphatic vessels. They are often aggressive and with a soft tissue lump with any of the following
metastasize locally and to distant sites. They can features, as these make a sarcoma more likely as
arise in sites of chronic lymphoedema or previ- the underlying diagnosis.
374 T. Wright et al.
GP / Secondary
Care
2 week wait referral
USS / MRI
MDT
Fig. 24.1 Example of a regional suspected soft tissue sarcoma referral pathway
• Increasing in size core biopsies are taken from different parts of the
• Size more than 5 cm lesion, especially if it appears heterogeneous on
• Painful imaging to provide maximum diagnostic yield. A
• Appears deep clinically or on a scan (Fig. 24.1) fine needle aspiration (FNA) is not usually rec-
ommended for suspected primary soft tissue sar-
Referred patients are clinically assessed coma. Small lesions (<2 cm) often have
through history and examination by a sarcoma non-specific features on ultrasound and MRI
specialist. Imaging and biopsy then complete the scans. The diagnostic yield can be low on core
clinical picture, followed by re-discussion at biopsy. Therefore, an excision biopsy may be
MDT to formulate a treatment plan. considered for these lesions. Excision or incision
Diagnostic Imaging: Ultrasound scan by a biopsies may also be considered to confirm recur-
specialist is normally the first-line investigation, rent or metastatic disease. If open biopsy is per-
ideally performed simultaneously with history formed, longitudinal incisions are made in the
and examination assessment. If there continues to extremities and in line with the eventual defini-
be suspicion of sarcoma, further imaging, usually tive resection incision and minimal contamina-
an MRI (Fig. 24.2), is performed. Additional tion of the surrounding tissues.
scans such as X-rays if bone involvement is sus-
pected or CT scans for retroperitoneal masses
may be performed. 24.6 Staging and Grading
Biopsy: An urgent biopsy is performed of Sarcoma
anyone with a suspected soft tissue sarcoma. The
aim of tissue biopsy is to confirm malignancy and The grade of a tumour is a description based on
provide information on grade and subtype of sar- how abnormal the cell looks on histology and
coma, which in turn directs subsequent provides crucial prognostic information. The
management. Fédération Nationale des Centres de Lutte Contre
Usually a percutaneous core needle biopsy is le Cancer (FNCLCC) grading system [2] is
performed under ultrasound or CT guidance by generally used for soft tissue sarcomas. This sys-
an experienced sarcoma radiologist. The biopsy tem provides categories (well, moderate and
is planned in a way that allows removal of the poor) depending on tumour differentiation,
biopsy track during definitive surgery. Multiple necrosis and mitotic count (Table 24.1).
24 Sarcoma 375
Fig. 24.2 Appearance of lipomatous lesions on MRI. (Left): Homogeneous appearance likely to be benign. (Right):
Heterogeneous appearance suspicious of malignancy
Table 24.1 FNLCC histological grading criteria Table 24.2 AJCC staging system for soft tissue sarcoma.
Tumour Mitotic count (n per The eighth version sub-classifies the system for different
differentiation Necrosis high-power fields) anatomical locations
1. Well 0:Absent 1:n < 10 Stage
2. Moderate 1:<50% 2:10–19 I
3. Poor 2:≥50% 3:n ≥ 20 1A Low grade, small (G1/X, T1a/b)
(anaplastic) 1B Low grade, large (G1/X, T2a/b, N0)
The sum of the scores of the three criteria determines the Stage
grade of malignancy. Grade 1 = 2 or 3; Grade 2 = 4 or 5; II
Grade 3 = 6 IIA Intermediate or high grade, small (G2/3, T1a/b,
N0, M0)
IIB Intermediate grade, large (G2, T2a/b, N0, M0)
It is important to note that some sarcomas may
Stage High grade, large, (G3, T2a/b, N0, M0)
have uniform histological features despite being III Regional node involvement, with any size and
higher grade. Increasingly, molecular pathology- grade of primary tumour (G1–G3, T1–T2, N1,
based tests such as fluorescent in situ hybridiza- M0)
tion (FISH) are used to complement traditional Stage Metastasis identified (G1–G3, T1–T2, N0–N1,
IV M1)
techniques (based on morphology and immuno-
histochemistry) to aid diagnosis of sarcoma. For
example, A FISH test for the MDM2 locus can be Imaging for staging: This is performed
used to differentiate between a lipoma and a once a diagnosis of soft tissue sarcoma has
well-differentiated liposarcoma. been confirmed on biopsy. A staging CT chest
Staging of a cancer indicates the extent of the is performed prior to definitive treatment to
disease by describing its size and spread to other exclude pulmonary metastases. A CT scan for
parts of the body. The most widely used staging the abdomen and pelvis may be considered for
system for soft tissue sarcoma is from the lower extremity sarcomas. Additional scans
American Joint Committee on Cancer (AJCC). may be performed depending on the subtype of
Findings from physical examination, imaging the sarcoma—this may be to assess regional
scans and grade of the sarcoma are used as part of nodal basins or because of known metastatic
the staging process. patterns. MRI scanning, if not already per-
Once all information is available, the final formed, may be required to determine anatomi-
staging as per AJCC [3] is as follows (Table 24.2): cal boundaries and whether a tumour is
376 T. Wright et al.
surgically resectable. Whole body MRI scans blood vessels, potentially leaving microscopic
or PET-CT scans, although not routinely used, tumour in situ (LR rate 40–60%). There is no
can provide useful information in detecting difference between patients undergoing
metastases in some patients. A chest X-ray can unplanned excision and planned excision
be considered sufficient instead of a CT scan regarding local recurrence and overall survival.
for certain low-grade sarcomas due to very low The planned excision group has a higher risk of
metastatic potential. distant metastasis, whereas there is a high rate
of residual cancer in the unplanned excision
group [4]. Wide local excision (WLE) involves
24.7 Management of Soft Tissue removing the tumour in its entirety with a surgi-
Sarcomas cal margin of 1–3 cm (depending on feasibility)
or a clear fascial plane (LR rate ≤ 10%). Radical
The management of STS is primarily surgical. excision includes compartmental excision and
Depending on the grade of tumour, patients may amputation. Although gaining greater surgical
be offered radiotherapy either before (neoadju- clearance, both carry higher surgical morbidity
vant) or after (adjuvant) surgery to reduce the risk and post-operative functional loss (LR rate
of disease recurrence. 0.5%). As with many malignant tumours, prog-
Chemotherapy tends to be reserved for nosis is not significantly improved by radical
advanced or metastatic disease but is considered procedures [5].
as neoadjuvant therapy for certain sub-types such
as synovial or Ewing’s sarcoma, in combination
with surgery and radiotherapy.
Pearls and Pitfalls
Such options may confuse the onlooker. In
24.8 Surgical Management general, the main priority is excision of
tumour with clear histological margins.
When planning surgery, patient comorbidities, This includes planning the excision to
topographical anatomy and tumour stage and include any previous cutaneous biopsy
grade must be considered. Detailed surgical plan- sites and meticulous surgery with adequate
ning and reconstruction are made after a full margins, to avoid contamination of the sur-
MDT discussion. Patients with inoperable gical bed. How radically to excise a tumour
tumours, or with metastatic spread, are consid- will depend on the extent of surgery a
ered for palliative radiotherapy, chemotherapy or patient will physiologically tolerate, their
best supportive care. An important measure of rehabilitation potential, the reconstructive
successful sarcoma treatment is the surgical options and the proximity to vital struc-
tumour margin. Broadly, there are four types of tures which removal will significantly
excision: (1) intra-lesional; (2) marginal; (3) affect function. Pre-operative radiotherapy
wide local; and (4) radical. of high-risk soft-tissue sarcomas allows for
Intra-lesional excision (or ‘whoops’ opera- good local control rate at the expense of
tion) is usually as a result of inadequate pre- local wound complications, which are,
operative assessment, often in a non-specialist however, manageable with plastic surgical
unit where a lesion has been assumed benign. techniques. For this reason, plastic and
Macroscopic tumour is left in situ, and the prog- reconstructive surgeons are in the best
nosis is worse with local recurrence (LR) rates position to advise patients in treatment, of
of 80–100%. Sometimes, marginal excision which there is likely to be a choice of
may be required, due to tumour proximity next options.
to critical structures, such as major nerves and
24 Sarcoma 377
24.8.2 E
xample 2: Chimeric Free (MRI top left, tumour resection top right), recon-
Flaps structed with chimeric neurotized latissimus flap
to restore hamstrings and parascapular/scapular
A sarcoma of the flexor compartment of the flap for skin cover (defect bottom left, flap in situ
thigh, adjacent to but not involving sciatic nerve bottom right)
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 383
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_25
384 J. Masia et al.
made individually in order to guarantee oncolog- radiotherapy treatment, the timing is usually
ical safety and to optimize functional, aesthetic managed according to the protocol at each insti-
results. tution, and this will probably determine the
Immediate breast reconstruction is increasingly choice of the reconstructive technique.
considered an option in patients undergoing onco- Taking these considerations into account,
logic breast surgery. Although it represents an when deciding the most appropriate reconstruc-
additional procedure to mastectomy, performing tive technique, the surgeon should assess the type
the two procedures in a single operation provides a of mastectomy to be performed and the quality of
considerable psychological benefit by avoiding the the remaining skin. Whatever the case, an accu-
emotional impact on body image after ablative rate preoperative evaluation of the patient’s
surgery. Additionally, when the native breast skin objectives and expectations plays an essential
envelope and inframammary fold are preserved, role when choosing the most adequate recon-
the reconstructed breast usually assumes a more structive technique. Therefore, so that surgical
natural cosmetic result (Table 25.1). strategies and possible outcomes are discussed,
In contrast, delayed breast reconstruction can and so that the patient’s requirements are consid-
be performed months and even years after breast ered, it is essential that effective communication
resection. It may be delayed for a number of rea- be established between the patient and the sur-
sons, including certain comorbidities and major geon from the onset.
risk factors such as advanced age, smoking, and
vascular disease, or in case of doubts about local
cancer control (Table 25.2). In the context of 25.2 Breast Reconstruction
with Prosthetic Devices
a b
c d
Fig. 25.1 Breast reconstruction with prepectoral implants wrapped in ADM, following bilateral subcutaneous mastec-
tomy. Preoperative (a, c) and postoperative (b, d) images
a b
Fig. 25.2 Tissue expander/implant-based reconstruction of the left breast and mastopexy of the right breast.
Preoperative (a) and postoperative (b) images
25 Breast Reconstructive Surgery 387
Table 25.4 Breast reconstruction with autologous the breast (the thoracodorsal region and abdo-
tissues men) that is transferred from its natural location
Advantages to the chest, maintaining the blood supply through
• Use of own tissue its native vascular pedicle. In general, these types
• Easier symmetry in unilateral cases
of flaps are technically less demanding, with
• Natural appearance and feeling breast that change
with the patient over time shorter operative times and a lower risk of partial
• Possibility of recovering breast sensivity or total flap failure. However, potential loss of
• The breast will gain and lose volume with body donor site function can result when the muscle is
weight variations included in the pedicle flap.
• Longevity of the reconstruction Alternatively, free flaps can be taken from
• Better tolerance of postmastectomy radiotherapy
areas close to or far from the breast. They are
Disadvantages
• Technically more demanding
disconnected from their native blood supply
• Additional scar in the donor site and reconnected in the chest to the internal
• Longer surgery and hospital stay mammary or thoracodorsal vessels using
• Longer recovery microsurgical techniques. The major advance
• More short-term complications (partial or complete in autologous breast reconstruction has been
flap failure and donor-site morbidity) the development of perforator flaps. These
allow the harvesting of more tissue, without
rials and their potential complications, the autol- sacrificing the underlying muscle and minimiz-
ogous tissue reconstruction can last forever, ing donor site morbidity. However, the proce-
allowing the patient to completely forget about dure is technically more demanding, with
the distressing event of breast cancer. longer operating times, prolonged hospital
Breast reconstruction with autologous tis- stays, and the relative risk of partial or total
sue, however, is technically more demanding, flap failure.
and operating time, hospitalization, and recov-
ery take longer. Although the success is very
high in the hands of experienced microsur- 25.3.2 Donor Sites
geons, this technique is not exempted from
short-term complications that can lead to par- Excellent results can be obtained with a variety
tial or total flap failure or to morbidity at the of flaps, from various donor sites (see below).
donor site, such as wound dehiscence, weak- The most commonly used flaps for breast recon-
ness, hernia or bulge, seroma, and contour struction are from the abdominal region. These
deformities (Table 25.4). The tendency to per- include the transverse rectus abdominis myocuta-
form unilateral or bilateral mastectomy and neous (TRAM) flap, the deep inferior epigastric
immediate reconstruction with autologous tis- artery perforator (DIEAP) flap, and the superfi-
sue has increased progressively. This type of cial inferior epigastric artery (SIEA) flap. Other
reconstruction is generally recommended for widely used flaps are those of the dorsal region,
patients who have adequate soft tissue excess at including the latissimus dorsi myocutaneous
the donor site and do not want to use alloplastic (LDM) flap, and the thoracodorsal artery perfora-
materials for breast reconstruction. tor (TDAP) flap.
Donor sites that have gained popularity as an
alternative to abdominal flaps include the gluteal
25.3.1 Types of Autologous region with the superior gluteal artery perforator
Reconstruction (SGAP) flap, the lumbar region that provides the
lumbar artery perforator (LAP) flap, and the
Broadly speaking, autologous breast reconstruc- thighs that include the transverse or diagonal
tion can be performed using pedicled flaps or free upper gracilis (TUG, DUG) flaps and the pro-
flaps. Pedicled flaps originate from tissue close to funda artery perforator (PAP) flap.
25 Breast Reconstructive Surgery 389
sary to combine this technique with the use of TRAM flap is therefore not indicated in obese
breast implants. Regarding muscle transposition, patients or in those considering pregnancy.
dynamic weakness may occur in the extension
and adduction of the shoulder and may hinder the
Key Point
performance of certain sports and even daily
The TRAM flap is also one of the last
activities [22].
options for breast reconstruction due to its
considerable comorbidity at the donor site.
Key Point However, it is still the chosen technique in
The result that can be achieved with the many parts of the world.
LDM flap is frequently satisfactory, but it is
currently one of the last options for breast
reconstruction. 25.3.2.3 DIEAP Flap
In 1979, for the first time, Holmstrom reported
the transfer of a free transverse-oriented myocu-
25.3.2.2 TRAM Flap taneous flap from the abdominal region based on
The first breast reconstructions with abdominal tis- the deep inferior epigastric vessels [29].
sue were performed by Sir Harold Gillies in the Nevertheless, the great advance in autologous
1940s [23]. These procedures consisted of the breast reconstruction with abdominal tissue
staged transfer of a tubed abdominal flap, incorpo- occurred with the development of perforator
rating the umbilicus for the “nipple.” Later, in flaps. In 1989, Koshima and Soeda [30] pub-
1977, Drever reported the transfer of a vertically lished the use of abdominal flaps based on perfo-
oriented skin-muscle flap of the rectus abdominis, rators of the deep inferior epigastric vessels
based on the deep superior epigastric vessels, tun- without the rectus abdominal muscle. In 1994,
neled to the mammary region [24]. In 1979, Allen and Treece [31] described its application
Robbins described a similar vertically oriented for breast reconstruction, and together with
abdominal flap for breast reconstruction [25]. Soon Blondeel [32], they expanded the use of this tech-
after this, in 1982, Hartrampf et al. [26] reported nique to a high technical level, after which it
and popularized the use of a transversely oriented quickly gained great popularity worldwide.
rectus abdominis myocutaneous pedicle flap. The DIEAP flap provides a large amount of
The TRAM flap has a reliable and extensive well-vascularized skin and subcutaneous tissue
vascular pedicle which allows a wide arc of rota- and a pedicle of good length and caliber. It offers
tion to be tunneled through the thoracic- a natural and permanent result with minimal
abdominal region and be inserted in the ipsilateral morbidity at the donor site because the rectus
or contralateral mammary region. It even allows abdominus muscle is not sacrificed; the incidence
the safe transfer of a large amount of tissue with of hernias and abdominal bulging therefore
characteristics that are very similar to those of a decreases considerably [33]. This technique also
natural breast, without the need for microsurgery, improves the body contour of the abdomen, leav-
and within a relatively short operating time. ing a well-hidden scar. Compared with the
The most significant comorbidity of this tech- TRAM flap, postoperative pain is minimal, the
nique is the resulting abdominal-wall weakness. recovery period is shorter, and the patient returns
Although there is an aesthetic improvement in to normal life more rapidly.
the abdominal area, a localized bulge is often Nevertheless, a few aspects of this technique
observed in the para-infra-umbilical region, cor- can be considered disadvantages. Like other per-
responding to the muscle defect [27]. Nonetheless, forator flaps, the intervention requires a longer
the incidence of abdominal bulges and hernia can learning curve and considerable experience in
be significantly decreased by repair of the ante- microsurgical techniques. Preoperative assess-
rior rectus with the placement of a polypropylene ment with computed tomography (CT)
mesh [28]. Breast reconstruction with a pedicled angiography is essential go locate the dominant
25 Breast Reconstructive Surgery 391
a b
c d
Fig. 25.4 Left breast reconstruction with DIEAP flap and contralateral augmentation mammoplasty. Preoperative (a,
c) and postoperative (b, d) images
392 J. Masia et al.
section. Besides, as there is no need to perform a described the gluteal flap based on perforators of
fasciotomy and myotomy, the integrity of the the superior gluteal artery in 1993 [42], and its
abdominal wall is not altered, thus, morbidity at application for breast reconstruction was reported
the donor site is minimal [39]. in 1995 by Allen and Tucker [43].
Nonetheless, the SIEA is anatomically incon- The adipocutaneous tissue of the upper gluteal
stant. It may not therefore be available for use in area is a suitable option for breast reconstruction
all possible candidates. Besides, its short pedicle due to its consistency, volume, and reliable anat-
and small arterial caliber make anastomosis with omy. However, harvesting the SGAP flap can be
the recipient-site vessels technically more challenging because of the complexity of the
demanding. Another disadvantage is that the intramuscular dissection of the short pedicle
cutaneous territory irrigated by the SIEA is (5–7 cm). In this context, CT angiography can be
mainly limited to the ipsilateral hemiabdomen, very helpful to preoperatively identify the trajec-
so if all the lower abdominal tissue is needed to tory of the suitable perforator. Furthermore, in
perform a unilateral breast reconstruction, an most cases, it is necessary to use arterial and
extra anastomosis will be necessary to ensure the venous grafts to increase the length and match
vascularization of the entire flap. the caliber to the recipient-site vessels. Likewise,
To perform safe surgery with this flap, intra- during the dissection, special care must be taken
operative comparison of vascular dominance of to avoid damaging vital anatomic structures that
the superficial inferior epigastric system and the emerge caudally to the piriformis muscle, such as
deep inferior epigastric system is essential. When the sciatic nerve, the inferior gluteal artery, the
perfusion of the superficial system is not ade- internal pudendal artery, and the posterior femo-
quate, it is advisable to perform a DIEAP flap. ral cutaneous nerve.
Special attention is necessary to identify abdomi- Although the donor site scar can be well hid-
nal scars that may contraindicate the use of this den by underwear, the contour defect produced in
flap, such as the lower transverse abdominal scar the upper part of the buttock can be significant,
(Pfannestiel). requiring secondary refinement with lipofilling at
the donor site in almost all cases.
Key Point
The indications for SIEA flap breast recon- Key Point
struction are practically the same as those for The SGAP flap has become a valuable
the DIEAP flap, and it is a good option for alternative for autologous breast recon-
women with small breasts who undergo bilat- struction when the abdominal tissue is not
eral breast reconstruction (Fig. 25.5). adequate, especially in bilateral breast
reconstructions and in patients considering
pregnancy after breast reconstruction
(Fig. 25.6).
25.3.2.5 SGAP Flap
As early as 1920, Sir Harold Gillies advocated a
tube pedicle to transfer a slice of skin and fat
from the buttock to create a breast [23]. In 1973, 25.3.2.6 LAP Flap
Orticochea published the first report on the trans- In 1978, Hill et al. published the anatomical basis
plantation of a myocutaneous flap from the glu- of a transverse lumbosacral back flap and its use
teal region, in multiple stages, using the volar as a transposition flap based on the intercostal and
aspect of the forearm as a transport medium to lumbar perforators [44]. Nonetheless, the first
reconstruct the breast [40]. Shortly afterward, in description of the anatomical path and vascular
1975, Fujino et al. reported the use of a free myo- territory of the lumbar artery perforators was pub-
cutaneous flap based on the superior gluteal lished in 1999, by Kato et al. [45]. Later, in 2003,
artery for breast reconstruction [41]. With the De Weerd et al. [46] reported the use of a free
advent of perforator flaps, Koshima et al. LAP flap for breast reconstruction.
25 Breast Reconstructive Surgery 393
a b
c d
Fig. 25.5 Right breast reconstruction with SIEAP flap and contralateral mastopexy. Preoperative (a, c) and postopera-
tive (b, d) images
The donor site area for this flap is essentially Regarding the resulting donor-site scar, some-
the same as that for a traditional buttock lift. The times, it may be slightly high, making it difficult
fatty tissue tends to be less sturdy than that of the to hide with underwear. Besides, a sensory deficit
SGAP flap, making shaping of the new breast may occur in the upper gluteus due to the section
easier. Nonetheless, harvesting a LAP flap can be of the cluneal nerve during flap dissection, espe-
challenging even for experienced microsurgeons cially when looking for a sensitive flap, but this
in terms of perforator identification and dissec- rarely bothers the patient. Moreover, unilateral
tion through the thoracolumbar fascia. In addi- harvesting of the LAP flap may frequently require
tion, the pedicle can be rather short (average liposuction of the contralateral lumbar region to
6–7 cm), and there tends to be a size discrepancy symmetrize the contour.
between the diameter of the lumbar perforators
and the recipient-site vessels, making the use of
Key Point
an interposition arterial and venous graft neces-
The LAP flap is among the most complex
sary. To facilitate flap design and harvest, preop-
flaps in the microsurgeon’s armamentarium
erative planning with CT angiography is therefore
and is a reliable alternative when abdominal
crucial to assess the location and trajectory of the
and gluteal areas are not available (Fig. 25.7).
perforators [47].
394 J. Masia et al.
a b
c d
Fig. 25.6 Bilateral breast reconstruction with SGAP flaps following subcutaneous mastectomies. Preoperative (a, c)
and postoperative (b, d, e) images
25 Breast Reconstructive Surgery 395
a b
c d
Fig. 25.7 Right breast reconstruction with LAP flap. Preoperative (a, c) and postoperative (b, d) images
396 J. Masia et al.
a b
Fig. 25.8 Left breast reconstruction with TDAP flap and implant. Preoperative (a) and postoperative (b, c) images.
25 Breast Reconstructive Surgery 397
Key Point
The thigh-based flaps provide soft and pliable
tissue that is suitable for breast reconstruction
in patient with small breasts. Besides, they
also add the option of bilateral harvesting and
simultaneous breast reconstructions.
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21. Fisher J, Bostwick J, Powell RW. Latissimus 1991;27(4):351–4.
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1983;72(4):502–11. rior epigastric artery (SIEA) flap. Br J Plast Surg.
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Abdominal Wall Surgery
26
Paolo Persichetti, Silvia Ciarrocchi,
and Beniamino Brunetti
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 401
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_26
402 P. Persichetti et al.
wall structures or full-thickness defects may sig- cies, physical activity, age, abdominal surgeries, or
nificantly affect these functions. The goals of genetic conformation. The skin is mobile com-
abdominal wall reconstruction are to treat any pared to the musculoaponeurotic plane below.
abdominal open wounds, providing a complete On the abdominal wall, the minimum skin
soft-tissue coverage, to restore and reinforce fas- tension lines, or Langer lines, are oriented in a
cial integrity, to protect abdominal viscera, to horizontal or oblique direction, thus defining the
restore function, and to prevent hernias according best direction for surgical incisions. Between
to the “like-with-like” principle of reconstructive these lines, which can be real skin folds, we can
surgery [1]. The decision to perform an immedi- identify the suprapubic fold (site of Pfannenstiel
ate or a delayed reconstruction must be taken incision) and the infraumbilical fold, which
after having considered the patient’s comorbidities unites the two anterosuperior iliac spines, approx-
and clinical condition, the etiology and type of imately in the middle of the navel-pubis line.
the defect, and the infective status of the wound. The quality of the skin differs depending on
If possible, an immediate reconstruction is the subunits of the abdomen: the subcutaneous
always preferable, due to the benefits that this tissue below the umbilicus is more represented,
kind of approach brings from a psychological giving this region a softer and more relaxed tex-
and medical point of view. When that is impos- ture, compared to the supra-umbilical region. In
sible, an adequate abdominal coverage is per- men, the adipose plane tends to thicken sub-
formed to provide temporary closure; in such umbilically and laterally at the hip level.
conditions, vacuum-assisted closure therapy In women, fat distribution is commonly
reduces bacterial colonization and aids in keep- located at the sub-umbilical level and in the peri-
ing the wound clean by improving vasculariza- umbilical region. This distribution determines the
tion and minimizing wound inflammation. so-called “round abdomen” appearance. It is
Acquired abdominal wall defects represent important to check the quality of the skin, the
the focus of this chapter. presence and the distribution of abdominal scars,
and the existence of stretch marks. The abdomen
is divided into four quadrants and nine regions; in
26.2 Surgical Anatomy the region above the umbilicus, the Camper fas-
cia and Scarpa fascia are usually adherent to each
A thorough understanding of the anatomy of the other and form a single layer. They split below
abdominal wall is essential when planning recon- the umbilicus, forming:
struction. The abdominal wall is defined as the part
of the trunk that is bounded laterally by the right and • Camper fascia, a thick fibrofatty tissue layer
left mid-axillary lines; superiorly by the costoxi- that extends from the xiphoid process and the
phoid margins; and inferiorly by the pubic crest, the lateral costal margins to the inguinal ligament
inguinal ligaments, and anterior halves of the iliac bilaterally, and it continues inferiorly past the
crests. The anterolateral abdominal wall is made up inguinal ligament as the subcutaneous fat of
of several layers, which from the outside to the the thigh. It lies deep in the skin, but superfi-
inside are represented by the skin, subcutaneous tis- cial to the Scarpa’s fascia, and it is composed
sue of variable thickness with its fasciae, three fas- by a three-dimensional architecture of fibrous
cia layers and five paired symmetrical muscles, septae, which provides support for the adipose
transversalis fascia, and parietal peritoneum. tissue.
• Scarpa fascia is a thin and more membranous
layer, loosely connected to the aponeurosis of
26.2.1 Anatomy of the Integument the obliquus externus abdominis by areolar
tissue, but closely adhered in the middle line
The skin envelope is related to body habitus and is to the linea alba and to the symphysis pubis,
certainly more prone to undergo drastic changes and is prolonged on to the dorsum of the penis,
due to massive weight gain and/or loss, pregnan- forming the fundiform ligament [2].
26 Abdominal Wall Surgery 403
26.2.3 A
natomy of Vessels, Nerves,
Key Points and Lymphatics
The rectus muscle presents an anterior and
posterior sheet for most of its length: the The vascular supply to the abdomen can be sub-
anterior sheet is formed by the aponeuroses divided into three zones (Huger’s zones I, II, and
of the external oblique and the anterior leaf III) based upon regional anatomy as described by
of the aponeurosis of internal oblique, Huger (Fig. 26.2) [5]. The first zone corresponds
whereas the posterior is formed by the pos- to the middle part of the abdomen and is vascu-
terior leaf of the internal oblique and the larized by the perforating branches of the supe-
aponeuroses of the transversus abdominis. rior epigastric artery and inferior epigastric
Midway between the umbilicus and the artery, which anastomose within the rectus mus-
pubic symphysis, all the aponeuroses move cle fascia. The second zone corresponds to the
to the anterior sheet. At this point, the pos- hypogastrium and is nourished by the superficial
terior sheet becomes thinner leaving the circumflex artery, the superficial epigastric artery,
rectus abdominis in direct contact with the and some perforating branches from the proximal
transversalis fascia. This demarcation point segment of the inferior epigastric artery. The
is called the arcuate line. third zone includes the lateral areas of the abdo-
men and is supplied by the perforating branches
External oblique M
Rectus abdominis M
Linea semilunaris
Internal oblique M
Linea alba Anterior Rectus Sheath
Transversus abdominis M
External oblique M
Rectus abdominis M
Linea semilunaris
Internal oblique M
Linea alba Anterior Rectus Sheath
Transverse abdominis M
Fig. 26.1 Myofascial abdominal wall anatomy. Difference between above and below arcuate line. (Illustration by
Federico Di Crescenzo)
26 Abdominal Wall Surgery 405
Key Points
Vascularization of the abdominal wall must
always be kept in mind when approaching
Fig. 26.2 Vascular zones of the abdominal wall (Huger’s
zones). (Illustration by Federico Di Crescenzo) both reconstructive and aesthetic surgery
procedures to minimize complications. In
patients with previous abdominal scars and
from the diaphragmatic, intercostal, and lumbar
associated comorbidities, wide undermin-
arteries. The third zone is responsible for the vas-
ing should be avoided, and as many perfo-
cularization of the lateral cutaneous flaps
rators as possible should be spared.
advanced caudally during abdominoplasty proce-
dures; when such branches are spared, there is no
increased risk of marginal skin necrosis [6].
The venous drainage of the abdominal wall 26.3 Classification
superior to the umbilicus is via the internal mam- of the Abdominal Wall
mary, intercostal, and long thoracic veins: these Defects
veins ultimately drain into the superior vena cava.
Inferior to the umbilicus, the venous drainage is Abdominal wall defects can be classified in con-
via the superficial epigastric, circumflex iliac, genital or acquired based on their pathogenesis
and pudendal veins, eventually draining to the and may be asymptomatic or symptomatic
groin in the saphenofemoral junction and, ulti- (Tab1). Such defects may produce a wide variety
mately, to the inferior vena cava. of clinical issues ranging from minor cosmetic
The lymphatic vessels of the abdominal wall impairment to major destructive conditions
are organized according to two systems, one (Table 26.1).
superficial and the other one deep. The superfi-
cial one is in the soft tissue above the deep mus-
cular fascia, and it accompanies the subcutaneous 26.3.1 Congenital Defects
blood vessels below the dermis. Vessels from the
infra-umbilical skin run with the superficial epi- Congenital defects are due to an incomplete clo-
gastric vessels and drain into the superficial sure of the abdominal wall during embryogene-
inguinal nodes; the supra-umbilical region is sis, including omphalocele, umbilical hernia,
drained by axillary and parasternal nodes. The gastroschisis, and bladder exstrophy; nowadays,
406 P. Persichetti et al.
26.3.1.2 Gastroschisis
Gastroschisis is the protrusion of abdominal wall 26.3.2 Acquired Defects
contents through a defect in the abdominal wall
that is not in the midline, but usually to the right The acquired defects can be divided into:
of the umbilicus, with no covering membrane or
sac. The incidence of gastroschisis is about 0.5– 1. Partial abdominal defects
4.5 cases per 10,000 living births [8–10]. The 2. Full-thickness defects
cause of this defect is still unknown. This condi-
tion is not generally associated with other major 26.3.2.1 Partial Defects
congenital or chromosomal anomalies.
Gastroschisis is often classified into simple (iso- Diastasis Recti
lated defect) and complex (associated with Diastasis recti is not a true abdominal wall fascial
bowel-related complications: intestinal atresia, defect, but a common condition characterized by
perforation, stenosis, or volvulus) [8, 10]. the separation of the two rectus abdominis
26 Abdominal Wall Surgery 407
Fig. 26.3 On the left, normal anatomy of the rectus abdominis muscles and the linea alba. On the right, diastasis recti
with increase of the inter-recti distance. (Illustration by Federico Di Crescenzo)
408 P. Persichetti et al.
is the second most common type of hernia in supra-iliac region: the superficial lumbar Petit’s
adults following inguinal hernia. It accounts for triangle and the quadrilateral area of Grynfeltt.
6–14% of all abdominal wall hernias in adults Petit, in 1738, described one of the first cases of
[15]. Unlike in children, the adult umbilical her- complicated lumbar hernia which appeared in a
nia has no tendency to spontaneous regression triangle bounded by the iliac crest, the external
and must always be operated, considering the oblique muscle, and the latissimus dorsi muscle
high risk of incarceration related to it. Narrow- (named from him the Petit’s triangle). On the
neck hernias are at greater risk for incarceration other hand, the space described in 1866 by
and strangulation of bowel, whereas large-neck Grynfeltt is bordered by latissimus dorsi muscle
hernias are less likely to cause bowel trauma. The at the level of the XII rib, the posterior margin of
navel is the scar located in the center of the xipho- internal oblique muscle, and the serratus muscle.
pubic line and consists of a fibrous ring covered The area of greatest weakness is represented by
by the pre-peritoneal tissue and by the perito- the aponeurosis of the transverse muscle, due to
neum; this represents a locus minoris resistentiae. the passage of three muscular nerve pedicles.
In adulthood, it measures 2–3 mm, but it can be Such “costo-iliac” hernias can vary between 2
wider in predisposed patients. Abdominal disten- and 20 cm in diameter. Other abdominal wall her-
sion is a risk factor for umbilical hernias; this is nias are represented by inguinal and crural
the reason why they are more frequently found in hernias.
multipares, in cirrhotic patients, and in the obese. Inguinal hernia can be classified as:
Diagnosis is clinical and is easier in normal-
weight or underweight patients when an umbili- –– External or indirect oblique hernias, also
cal bulging appears during the Valsalva maneuver. called “lateral hernias”; they are the most fre-
Umbilical hernias are generally asymptomatic, quent, involving peritoneal sac, which is
becoming symptomatic in case of strangulation externalized through the lateral inguinal dim-
or incarceration. When diagnosis is doubtful or ple, lateral to the epigastric vessels. Usually,
when it is indicated to study the accompanying the sac is intra-funicular and corresponds to
diastasis, ultrasound or CT exams are useful. the persistence of the peritoneo-vaginal duct.
Epigastric hernia occurs when an area of It develops like a “glove finger” inside the
weakness in the abdominal wall allows pre- fibro-cremasteric sheath and follows the way
peritoneal fat to push through; these kinds of her- of the funiculus.
nias are typically small. They occur in the area –– Direct hernias, also called “medial”: they
between the navel and the breastbone. These her- exteriorize from the dimple medial inguinal,
nias typically do not cause symptoms, but the medial to the epigastric vessels. Usually, the
patients may experience pain in the upper abdo- sac is wider than long and spheroidal and cor-
men. It is important for the surgeon to know that responds to a prolonged relaxation of the
some patients develop more than one epigastric transversalis fascia a level of the medial ingui-
hernia at a time. nal dimple. Sometimes the sack externalizes
Lateral hernias include Spigelian hernias, through a limited orifice and takes a diverticu-
which might appear on the semilunar line at the lar aspect.
level of the external margin of the rectus abdomi- –– Internal oblique hernias are located at the level
nis muscle; this line extends from the anterior of the internal inguinal dimple, medial to the
margin of the IX costal cartilage to the pubis. umbilical artery, and are externalized at the
They are usually found below the umbilical level inner corner of the inguinal duct. They are
due to dehiscence of the transversus aponeurosis exceptional.
and internal oblique muscle which appear to be
weaker in the vicinity of the semilunaris line. Crural hernias, also called “femoral,” are
Lumbar hernias come out through one or both rarer than inguinal and more frequent in females.
areas of least resistance in the posterolateral Crural hernias do externalize through the sheath
26 Abdominal Wall Surgery 409
of the femoral vessels, which extends the trans- port when it is still small. In mobile hernias, syn-
versalis fascia to the thigh. This sheath is chronous with the acts of breathing, the viscera
normally narrow around the femoral vessels,
are rhythmically pushed through the hernial gate
except at the level of the medial aspect of the out of the abdominal cavity, and the activity of
femoral vein. It is at this level that common cru- the diaphragm is seriously compromised; the
ral hernias develop. The sack pushes through the movements of the abdominal wall become irreg-
crural ring, below the crural arch, medial to the ular during the phases of breathing with subse-
femoral vein. quent worsening of the respiratory function. It is
useful for surgical planning to perform instru-
Postoperative or Incisional Hernia mental examinations like a CT scan to investigate
Incisional hernia is defined as the herniation defect depth (full or partial thickness), the pres-
below the cutaneous plane of abdominal viscera, ence of both rectus abdominis muscles, and hori-
through a previous laparotomy incision, repre- zontal diameter between the rectus abdominis
senting a rather frequent complication of abdom- and perforators’ anatomy.
inal surgery. In most cases, it appears in the first
year after surgery, representing a complication, 26.3.2.2 Full-Thickness Defects
and it is often a source of long-term morbidity.
Based on anatomical and clinical criteria, inci- Traumatic Defects
sional hernias can be distinguished in median and Acquired or full-thickness defects generally
lateral hernias. The median ones, originating at result from different conditions like previous sur-
the linea alba, are the most frequent, representing gery, trauma, infections, and tumor resections.
a 75–90% of the total; among the lateral hernias, Massive abdominal wall defect is a challenge to
less frequent than the median (10–25% of total), any reconstructive surgeon. Defects due to any
the subcostal and inguino-iliac ones are the most trauma are very difficult to manage due to associ-
common, in most of the cases located, respec- ated injuries, infection, and non-availability of
tively, in the right hypochondrium, as conse- local tissues for reconstruction. Traumatic rup-
quence of biliary surgery, and right iliac fossa, ture of the abdominal wall is most commonly
following surgery for appendicular peritonitis or supraumbilical and is related to a concurrent
for gynecological pathologies [16]. Depending intra-abdominal injury. Plastic surgery is usually
on the size of the hernia gate, they can also be called not for the management of acute penetrat-
categorized as follows: small hernias (<5 cm), ing abdominal injury but for the repair of subse-
intermediate hernias (5–10 cm), large hernias quent loss of domain. Reconstructive surgeons
(>10 cm), and giant hernias (>20 cm). Incisional may also be called to evaluate wounds that have
hernia is an evolutionary disease, and when it been left temporarily open.
reaches a considerable size, it alters the physio-
logical balance between abdominal muscle activ- Oncological Defects
ity, abdominal pressure, and diaphragm activity History of abdominal neoplasm may complicate
causing the so-called laparocele disease with the reconstructive course: chemotherapy may
important muscular, respiratory, cardio-impede wound healing, and radiotherapy causes
circulatory, and visceral alterations. More than extensive tissue injury and may contribute to
the endoabdominal pressure is the lateral traction abdominal wall defects. Acute radiation injury
carried out on the linea alba by the contraction of poses several challenges: difficulty in distin-
the lateral muscles of the abdomen that contrib- guishing anatomical planes, extensive soft-tissue
utes to an increase of the fascial gap. This fibrosis, reduced tissue pliability, and prolonged
explains the natural trend of most ventral hernias healing time. The injury to a wound bed is mani-
to progressively increase in dimensions, unless fested by stasis or occlusion of the small vessels
scarring sclerosis acts to consolidate the hernial and decreased tensile strength.
410 P. Persichetti et al.
with diameters less than 1.0 cm almost always that reconstruction can be performed with well-
heal spontaneously before 6 years of age and vascularized, innervated, autologous tissue.
therefore rarely need surgical treatment. Fascial Partial myofascial defects are closed primarily
defects greater than 1.5 cm rarely heal spontane- whenever possible; the plication of the anterior
ously before age 6; such large defects should be and/or posterior rectus sheath is the most fre-
surgically corrected prior to age 6 to prevent quent procedure performed by plastic surgeons to
embarrassment in school [18]. Umbilical hernia correct deformities of the musculoaponeurotic
repair is a day case surgery performed under gen- layer involving the midline.
eral anesthesia; a semicircular periumbilical inci-
sion is usually made on the left margin of the Diastasis Repair
umbilical ring allowing to proceed with a dissec- The most common partial myofascial defect of
tion of the peritoneal sac at the deep face of the the abdominal wall is rectus diastasis, which usu-
skin of the navel. The aponeurotic margins of the ally needs surgical repair with different tech-
umbilical ring are then identified and carefully niques, either through an open or laparoscopic/
prepared, bringing them closer together with endoscopic procedure.
transverse stitches with non-absorbable suture. Open approach is performed during conven-
Umbilicoplasty may be performed, especially for tional abdominoplasty or mini abdominoplasty
those with a large umbilical hernia, to improve procedure, depending on the patient’s body shape
cosmetic results. and skin laxity: conventional abdominoplasty is
generally more suitable when there is redundant
skin excess and involves the transposition of the
26.4.2 Repair of Acquired Defects umbilicus which is detached from the skin but
remains connected to its stalk; mini abdomino-
Acquired defects of the abdominal wall are cate- plasty is usually performed in young women,
gorized in partial defects, which involve the loss when the abdominal skin tissue is elastic and
of either the skin and subcutaneous tissue or the involves a complete detachment of the navel from
myofascial tissue, and complete defects, involv- its pedicle, which remains adherent to the sur-
ing the full-thickness loss of both superficial and rounding skin. This procedure does not involve
musculofascial layers. the excision of abundant skin and subcutaneous
tissue. The concept of abdominoplasty surgery
26.4.2.1 Repair of Partial Defects has remained constant over the years. The pur-
Partial defects involving the skin and subcutane- pose is to improve the contour of the abdominal
ous tissues, if smaller than 5 cm in size, are usu- wall by means of rectus abdominis fascia plica-
ally closed primarily; defects between 5 and tion and removal of excess skin and fat from the
15 cm in size are closed either with local flaps lower abdominal region. These benefits are
(random flaps, perforator flaps) or a split tissue achieved using a low-lying suprapubic incision
skin graft or can also be managed with a vacuum- that can be hidden under the bikini line; anterior
assisted closure device. For defects greater than rectus sheath plication extends from the xiphoid
15 cm in size, options include pedicled or free appendix down to the suprapubic area. Plication
fasciocutaneous flaps or, alternatively, the use of of the anterior rectus sheath is performed with a
random flaps, whose use can be optimized with one- or two-layer synthetic, monofilament, non-
tissue expansion processes, which aid in tissue absorbable polypropylene suture. It is not uncom-
advancement and donor site closure. Expansion mon that some patients present persistent
of both sides of a defect improves the process of musculoaponeurotic flaccidity after correction of
reconstruction. The disadvantage of this tech- the diastasis. Therefore, when there is laxity in
nique is that it is a staged and lengthy procedure, the flank and hypogastric area after plication of
and there is also a possibility of exposure and the anterior rectus sheath, plication of the exter-
infection of the tissue expander. The advantage is nal oblique aponeurosis is an interesting
412 P. Persichetti et al.
a djunctive procedure that can be used to improve formed on the left side of the navel, which can be
overall tension of the musculoaponeurotic layer slightly prolonged on the midline above or below,
and to valorize the fine contour of the abdomen in and then the surgeon proceeds with sack isola-
thinner patients (Fig. 26.4). tion, disconnection from skin adhesions, and
In case of severe laxity, the use of a resorbable repositioning of its content into the abdominal
or no resorbable mesh can be considered; this cavity. When the tension is high after hernia cor-
might be placed over the anterior or posterior rec- rection, small fascial releasing incisions
tus sheath and anchored interrupted by using an (1–1, 50 mm on each side) are suggested. To
absorbable suture. Obtaining a complete cover- avoid hernia recurrence, a wall reinforcement
age of the mesh with the anterior rectus sheath with a prosthetic material is often necessary. This
layer is advisable to avoid complications. must be inserted deeply to limit the risk of infec-
tion, often between the peritoneum and posterior
Hernia Repair aponeurosis of the rectus sheath; a cleavage plane
The treatment of all umbilical hernias in adults is generally present between peritoneum and
must be surgical, considering the risk of strangu- muscle sheath. The laparoscopic approach is also
lation. It is performed under general anesthesia performed under general anesthesia, with an
that allows dissection in optimal conditions on a empty bladder. The patient is placed in a supine
curarized patient. There are different techniques position. The operation starts with the creation of
available: simple closure, closure with local the pneumoperitoneum. The trocar with optics is
plasty, or prosthetic reinforcement by conven- inserted lateral to the navel or in the suprapubic
tional or laparoscopic approach. The indication region. Two more 5 mm operating trocars are
for a specific technique depends on the size of the placed laterally; after exploring the peritoneal
hernia, skin conditions, and the surgeon’s prefer- cavity, the sac is freed from its adhesions, using
ence. Elliptical semi-circle skin incision is per- scissors and hook coagulator. If a prosthesis is
Fig. 26.4 Pre- and post-correction of a rectus diastasis and umbilical hernia with conventional abdominoplasty
26 Abdominal Wall Surgery 413
needed to be inserted, it is shaped and introduced line/umbilical region, and 1–3 cm in the suprapu-
in the abdominal cavity both through the optic bic area for a single side; therefore, a bilateral
trocar and through an additional 10 mm trocar. component separation can allow for closure of a
20-cm-wide fascial defect. Component separa-
Postoperative or Incisional Hernia Repair tion creates a dynamic repair by using incisions
Ventral hernias are one of the most common that create fascial release to bring the rectus mus-
abdominal wall defects faced by reconstructive cles together at the midline, thereby recreating an
surgeons, known for the high relapse rate and innervated, functional abdominal wall. When
surgical complications. It is important to note component separation is not feasible or is insuf-
that, despite advances in hernia repair techniques ficient to completely reduce the defect, surgeons
and technologies, recurrence following standard may consider bridging the defect with prosthetic
ventral herniorrhaphy remains unacceptably repair material (Fig. 26.5).
high. Evidence from the trial conducted by
Luijendijk suggests that nearly one quarter of
Tips and Tricks
ventral hernias repaired with synthetic mesh
recur within 3 years; this rate reaches 50% for Important things to consider for better out-
primary repair alone. In addition, the risk of her- comes in abdominal wall surgery:
nia recurrence increases with each additional
• According to the multidisciplinary
operation: the length of time between reopera-
approach, a good anesthesiologist-
tions was progressively shorter after each addi-
surgeon relationship is critical to achieve
tional hernia repair [19]. Postoperative
the best possible results; it is important
complications and recurrence are the two main
to avoid cough, nausea, vomiting, and
issues in ventral hernia repair; infection is a com-
abdominal contractions postoperatively.
mon and significant postoperative occurrence
• Wearing compression garments after
that increases the risk of hernia recurrence. Use
surgery will improve the patient’s recov-
of prosthetic repair material is highly recom-
ery and will reduce the rate of postop-
mended in order to reinforce the repair of all inci-
erative seromas.
sional ventral hernias, whether the midline fascia
• When dermolipectomy is performed,
can be re-approximated or not. Very small defects
tension-free sutures with layered
may be closed primarily along with reinforcing
abdominal closure are suggested, which
prosthetic repair material, potentially using a ret-
transfer the tension to the superficial
rorectus repair. Most defects too large for pri-
fascia system and not on the distal skin
mary repair can be closed with the component
flaps, in order to reduce skin flap necro-
separation technique and reinforced with pros-
sis and hypertrophic scars.
thetic repair material. In 1990, Ramirez pub-
• Get out of bed: moving around and
lished his work on local tissue transfer for the
walking in the days following surgery
repair of ventral hernias [20]. Component separa-
help in faster recovery while reducing
tion technique involves suprafascial lateral dis-
thromboembolic complications.
section to the midaxillary line, followed by a
fasciotomy through the external oblique aponeu-
rosis and then lateral dissection in the plane
between the external and internal oblique mus- Synthetic mesh is currently the most common
cles up to the midaxillary line. This avoids dam- repair material used for reinforcement of ventral
age to the neurovascular structures supplying the hernias; however, despite significant advantages
muscles, which travel in the plane between the such as reduced recurrence rates, ease of use, and
internal oblique and the transversus abdominis. comparatively low cost, permanent synthetic
These maneuvers allow medial advancement of mesh has certain drawbacks. These d isadvantages
3–5 cm in the epigastrium, 7–10 cm at the waist- include increased risk of visceral adhesions to the
414 P. Persichetti et al.
Fig. 26.5 Recurrent incisional hernia operated with a combination of mesh placement and component separation tech-
nique (Ramirez), which allowed bilateral advancement of the muscular layers with complete coverage of the mesh
repair site, erosion into the bowel leading to for- defect if reapproximating of the fascial edges is
mation of enterocutaneous fistulae and/or bowel not possible. There are several techniques that
obstruction, extrusion of the repair material, and have been described, according to the location of
infection. Following removal of an infected pros- the prosthesis: this can be sutured superficial to
thesis, the surgeon is left with a contaminated the primary repair of fascial edges (onlay), within
field and a hernia deficit larger than the original the myofascial layers (sublay), or beneath the
that still requires repair material. Surgeons must fascia and exposed to intraperitoneal contents
consider the use of biologic repair materials in (underlay). Overlay placement, therefore, may
place of permanent synthetic mesh, because of be preferred for types of synthetic mesh that are
their ability to support revascularization: these associated with formation of bowel adhesions to
materials are more resistant to infection and do minimize the risk that the mesh may erode into
not require removal when exposed or infected; the abdominal compartment and become exposed
furthermore, the ability of certain biologic pros- to the viscera. Bridging may not generally be rec-
theses to support revascularization may contrib- ommended except in cases where component
ute to clearance of a contaminated field. Biologic separation is not feasible or is insufficient to
repair materials have been successfully used to bring the fascial edges together. There are also
repair large contaminated and/or irradiated theoretical advantages to the placement of repair
abdominal wall defects in patients with cancer material as an underlay: when the material is
when placed directly over the bowel. The choice placed deep into the abdominal musculature,
between synthetic and biologic repair material increases in intra-abdominal pressure press the
for many surgeons is often based on several con- repair material into the defect and against the
siderations including cost, choice of technique, native tissue, rather than away from the defect.
technical expertise, and the risk for postoperative This technique also seems to have a lower recur-
complications. In open incisional hernia repair, rence rate.
prosthetic repair material may be placed to rein- Although recurrence rates following rein-
force a primary repair or to bridge a remaining forced laparoscopic hernia repair are comparable
26 Abdominal Wall Surgery 415
to those of open repair with reinforcement, there struction can be performed. Vacuum-assisted clo-
are several documented advantages of the laparo- sure devices are used in such cases; using this
scopic approach, including smaller incisions, adjunctive tool, a sterile foam dressing is placed
lower risk for complications, shorter hospital in the wound cavity with an evacuation tube
stay, and patient preference. However, seromas which exits the wound to create an airtight seal,
may be more common following laparoscopic and sub-atmospheric pressure is applied to the
hernia repair, due to the use of drains in the open foam dressing; this procedure ensures a complete
approach, which are not generally placed in lapa- sealing from the environment, a better vascular-
roscopic repairs. In addition, the limitations of ization of the wound bed, a decrease of bacterial
laparoscopic repair include the inability to restore colonization, an improvement of granulation tis-
functional abdominal wall anatomy, to manage sue while reducing the size of the defect, and
skin redundancy and the hernia sac. increased flap survival. Unstable or trauma
patients with full-thickness defects require recon-
struction of the different layers to restore muscu-
Key Point
lar function and replace skin and fascial gaps. In
Ventral hernias are one of the most com- such patients, a staged approach is preferred
mon abdominal wall defects faced by using a temporary vacuum-assisted closure
reconstructive surgeons. device and, if needed and possible, a planned tis-
Repair of giant incisional hernias can sue expansion procedure. Tissue expansion can
bring to an increase of intra-abdominal provide autogenous tissue to close skin and sub-
pressure and, sometimes, to abdominal cutaneous defects larger than 15 cm in size after
compartment syndrome. Patient optimiza- initially achieving temporary closure.
tion is crucial for the success of the Reconstruction requires expansion on both sides
intervention. of the defect. Despite being a lengthy, staged pro-
Given the high risk of recurrences, the cedure, it provides well-vascularized innervated
use of a prosthesis is mandatory and must autologous tissue for reconstruction. Expansion
be placed preferably between the muscular is achieved between external and internal oblique
plane and the posterior rectus sheath. In our or between internal oblique and transverses
experience, biologic mesh is the first abdominis muscles. Tissue expansion also
choice, given the lower infection rate. restores abdominal domain thus allowing easy
reduction of visceral contents of the ventral her-
nia and prevents postoperative respiratory dis-
26.4.2.2 Repair of Full-Thickness comfort [21].
Defects
Oncological Defects Repair
Traumatic Defects Repair Similar full-thickness defects are encountered
Traumatic accidents or, more commonly, onco- after oncological resection of soft tissue sarco-
logical resection (soft tissue sarcoma) may result mas or skin metastasis from other cancer invad-
in large full thickness of the abdominal wall. In ing the abdominal wall. In such cases,
trauma patients, especially with loss of domain, immediate reconstruction is needed to provide
delayed reconstructions are preferred. In such urgent coverage of exposed viscera. We should
cases, every effort should be made to achieve pri- support the use of mesh as a fascial repair in all
mary fascial closure after adequate debridement oncologic cases. For moderate-size defects
of any poor-quality, attenuated, scarred, dam- involving the lower abdominal wall and the
aged, or nonviable musculofascial tissue. In this inguinal region, local and/or locoregional pedi-
case, the wound is closed with a temporary cover cled flaps are used with success: in particular
and subsequently re-explored. A skin graft may the gold standard coverage is provided by the
be applied as a temporary measure until recon- use of tensor fascia lata flap and anterolateral
416 P. Persichetti et al.
Fig. 26.6 Microsurgical abdominal wall reconstruction with a KISS LD free flap after wide resection of dermatofibro-
sarcoma protuberans
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Lymphedema: Diagnosis
and Treatment
27
Peter C. Neligan
Background
Surgical options are excision and
Lymphedema refers to swelling of a limb
reconstructive.
secondary to malfunction of the lymphatic
The commonest type of excisional treat-
system from either congenital or acquired
ment is liposuction.
causes. Recent developments in the treat-
Lymphaticovenous bypass (LVB) and
ment of lymphedema have changed our
vascularized lymph node transplant
approach to management of these patients.
(VLNT) are the commonest reconstructive
New imaging modalities have provided a
procedures.
better understanding of the problem and
Prophylactic LVB is a good approach in
how it can be treated.
patients having lymphadenectomy.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 419
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_27
420 P. C. Neligan
action of lymphatic vessels [1]. If we look at edema. Morbid obesity has been associated with
experimentally induced lymphedema in animals, lower extremity lymphedema [8]. Lymphedema
whether by tail surgery, popliteal node excision, may be reversible if the patient loses weight.
or toxic injection, several things are consistently However, the commonest cause of lymphedema
seen in clinical lymphedema. These include we see is secondary to surgical procedures, often
fibro-adipose deposition, attenuated and eventu- combined with radiation. There is a lymphedema
ally absent lymph vessel pumping, and decreased incidence of approximately 25% following axil-
dendritic cell trafficking which decreases collat- lary node dissection and radiation. The incidence
eral vessel formation. So in lymphedema, we see in the lower extremity following groin dissection
a lack of collateral vessel formation compared, and radiation is even higher. For this reason, we
for example, with what we see in venous obstruc- are now able to prophylactically reconstruct the
tion. The other consistent finding is inflamma- lymphatics at the time of node dissection in these
tory cell infiltration [2]. This has led to the patients [9].
investigation of the efficacy of anti-inflammato-
ries in the treatment of lymphedema. There is
both animal and human evidence to show that 27.3 Patient Assessment
this deserves further investigation [3, 4]. All of
these things need to be kept in mind in dealing When presented with a patient with limb swell-
with these patients. ing, the diagnosis has firstly to be established
since there are many causes of limb swelling.
Assuming that lymphedema has been verified
27.2 Types of Lymphedema as the cause of the swelling, we then have to
assess the patient in order to choose the most
Lymphedema can result from any abnormality or appropriate treatment. History is important. It
injury to the lymphatic system. Lymphedema helps differentiate between primary and sec-
may be primary or secondary. Traditionally pri- ondary lymphedema. We also want to know the
mary lymphedema has been described relative to duration of the condition, any history of infec-
the time of presentation. Milroy’s disease, or type tion, and most importantly what treatment the
1 primary lymphedema, presents at or shortly patient has had and how they responded to that
after birth. It is related to a VEGF3 receptor treatment. On physical examination, we want
mutation. Type 2 primary lymphedema has two to ascertain whether or not the patient has any
iterations. Lymphedema praecox presents in the pitting. Pitting edema is diagnosed by firmly
late teen years, while lymphedema tarda presents pressing on the swollen body part for a minute.
in patients in their 30 s [5, 6]. If the imprint of the thumb is easily seen on
Acquired or secondary lymphedema is a release of the pressure, the patient has pitting
huge worldwide problem. Filariasis is by far the edema. We tend to see pitting in early lymph-
commonest cause of acquired lymphedema. It is edema, while later in the disease, there seems
a mosquito-borne condition in which the insect to be less pitting and a greater fibrofatty ele-
bites an infected individual and transfers the ment to the swelling. It is established both clin-
nematode to another individual. The larvae ically and experimentally that there is fibrofatty
mature in the lymphatic system, destroying the deposition in lymphedema [10, 11]. We want to
lymphatics [7]. This condition is endemic in determine if there are any trophic skin changes
many parts of the world. It is estimated that as this can increase the risk of infection, and,
70 m people worldwide have filariasis and of course, we want to determine whether there
120 m are at risk. is any sign if infection at the time of our exami-
There are many causes of secondary lymph- nation. We also want to perform some basic
edema. Essentially anything that blocks normal tests, and while none of these is a pathogno-
flow in the lymphatic system will cause lymph- monic of lymphedema, taken together, they are
27 Lymphedema: Diagnosis and Treatment 421
useful particularly as an ongoing assessment on the lymphatic channels (Fig. 27.1). It does
tool to measure the patient’s response to have an application however in reverse lymphatic
treatment. mapping. This is a technique that allows identifi-
cation of limb draining lymph nodes that must be
avoided when harvesting lymph nodes for vascu-
27.4 Limb Circumference larized lymph node transfer [17].
and Volume MR Lymphangiography: This technique not
only documents the lymphatics with high-qual-
To be of any use, we need to standardize how ity images, but it also gives good information
these measurements are made so they can be about the rest of limb. This can uncover unex-
reproduceable. Limb volume is of more use than pected findings that may be causing limb swell-
limb circumference measurements and can be ing. An example is shown in Fig. 27.2. One of
measured in a number of ways. Volume can be the difficulties with MR is telling lymphatics
calculated from limb circumference measure- apart from veins. Because of that, we introduced
ments, and Brõrson has published how this can
be done [12]. Volume has traditionally been mea-
sured by water displacement. Perometry can also
be used to measure volume [13, 14]. One final
tool that can be used to assess the lymphedema-
tous patient is bio-impedance spectroscopy. This
measures the time taken for a small electrical cur-
rent to pass through the tissues and is based on
the principle that the resistance to the passage of
a current through the tissues (impedance) is
inversely proportional to the amount of fluid in
the tissues [15].
27.5 Imaging
Fig. 27.2 This patient presented with bilateral lower extremity swelling, but MRI showed complete fatty degeneration
of his musculature which was the real cause of his limb swelling
a dual-agent technique [18, 19]. This involves described the different patterns that we see in
an intradermal injection of gadolinium and an lymphedema and correlated these patterns with
intravenous injection of Feraheme which sup- what we see clinically [20, 21] (Fig. 27.3). The
presses the venous signal allowing better visual- disadvantage of ICG is that only the superficial
ization of the lymphatics. One important part of lymphatics can be visualized. However, it is an
the MR examination is to look at the axillary invaluable tool.
veins in upper limb secondary lymphedema and Most recently, ultrahigh frequency ultrasound
the pelvic veins in lower extremity secondary has been introduced as a tool [22]. This has
lymphedema. This is because some of these opened up new horizons in the surgical manage-
patients show evidence of compression of the ment of lymphedema as lymphatic channels can
axillary or pelvic veins from a combination of now be clearly seen within areas of dermal back-
surgery and radiation, and excising the scar flow and targeted for lymphaticovenous bypass
from around these veins often improves their (LVB). In the past, we have avoided areas of der-
symptomatology. mal backflow for LVB because of the difficulty of
Fluorescent lymphangiography: This involves visualizing lymphatic channels with other
the use of indocyanine green (ICG). This is a imaging techniques. It has the added advantage
fluorescent dye that is activated by a laser light of also visualizing veins so that planning of the
source and visualized with a near infrared cam- LVB is simplified [23]. Most recently, the use of
era. This allows visualization of the superficial microscope integrated laser tomography has been
lymphatics. Koshima and his group have described [24].
27 Lymphedema: Diagnosis and Treatment 423
Fig. 27.3 This shows the different patterns seen with fluorescent lymphangiography, linear, splash, stardust, and dif-
fuse. These correspond to decreasing diameter of the lymphatics associated with increased sclerosis
27.7 Results
have had previous surgery, such as a lymph node
dissection, and those who have not had any surgery. Prophylactic lymphatic reconstruction does have a
The latter represent patients with primary lymph- place. Results have shown a reduction in the occur-
edema. In both of these categories, an excisional rence of lymphedema from approximately 25% to
procedure is offered, usually with liposuction. between 5 and 10% in patients who have undergone
However, if there are areas of dermal backflow, an axillary resection [29, 30]. LVB is also success-
426 P. C. Neligan
MRI
No Lymphatic Lymphatic
Dissection Liposuction
Dissection
ful and can reverse lymphedema completely in a 2. Ly CL, Kataru RP, Mehrara BJ. Inflammatory
small number of patients, though usually it does not manifestations of lymphedema. Int J Mol Sci.
2017;18(1):171.
cure lymphedema; rather, it improves it and pre- 3. Rockson SG, et al. Pilot studies demonstrate the poten-
vents progression. The same is true of VLNT [31]. tial benefits of antiinflammatory therapy in human
lymphedema. JCI Insight. 2018;3(20):e123775.
4. Nakamura K, et al. Anti-inflammatory pharmaco-
Take-Home Messages therapy with ketoprofen ameliorates experimental
• Lymphedema is a complex condition, lymphatic vascular insufficiency in mice. PLoS One.
and we have several options for 2009;4(12):e8380.
5. Lee BB, et al. Diagnosis and treatment of pri-
treatment. mary lymphedema. Consensus document of the
• Choosing the most appropriate treat- International Union of Phlebology (IUP)-2013. Int
ment is vital to successful outcome. Angiol. 2013;32(6):541–74.
6. Liu NF, et al. Rare variants in LAMA5 gene associ-
• It is important to weigh all the evidence
ated with FLT4 and FOXC2 mutations in primary
before making that choice. lymphedema may contribute to severity. Lymphology.
• There is no one test that can be used, 2016;49(4):192–204.
and many patients require multiple 7. Cano J, et al. The global distribution and transmission
limits of lymphatic filariasis: past and present. Parasit
investigations.
Vectors. 2014;7:466.
• Evidence is gathered by looking at all 8. Greene AK, Grant FD, Slavin SA. Lower-extremity
the information. lymphedema and elevated body-mass index. N Engl
• Setting appropriate expectations for the J Med. 2012;366(22):2136–7.
9. Boccardo F, et al. Lymphedema microsurgical preven-
patient is important.
tive healing approach: a new technique for primary
prevention of arm lymphedema after mastectomy.
Ann Surg Oncol. 2009;16(3):703–8.
10. Brorson H, et al. Adipose tissue dominates chronic
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Nerve Surgery
28
Alberto Bolletta and Emanuele Cigna
28.1 Introduction
Background
The ability to repair injuries of the periph-
The basic principles of nerve reconstruction are
eral nervous system in order to restore sensi-
largely based on the understanding of peripheral
tivity and motor function is an essential
nerve anatomy and physiology both from a mac-
aspect of reconstructive microsurgery today.
roscopic and microscopic point of view. In par-
In recent years, the increased understand-
ticular, the comprehension of fascicular
ing of nerve anatomy and pathophysiology
arrangements in specific nerves, together with the
has offered new insights, both in terms of
understanding of nerve physiology in terms of
comprehending nerve degeneration and
neurodegeneration and regeneration, has
regeneration processes and developing new
enhanced results of reconstructive techniques.
strategies for treatment. Technological
improvements have also had a significant
impact on this field. The use of high-resolu-
28.2 Nerve Anatomy
tion microscopes and thinner suturing mate-
rials, together with a better understanding of
The peripheral nervous system conveys signals
nerve regeneration, has facilitated the devel-
between the spinal cord and the rest of the body,
opment of more precise approaches to differ-
and it can be classified according to the function
ent types of injuries and enhanced outcomes.
of its fibers. The afferent arm consists of sensory
The purpose of this chapter is to provide a
neurons that transfer information from peripheral
detailed description of nerve anatomy and
receptors to the central nervous system. The
present current trends in surgical techniques
efferent arm is composed of neurons transmitting
for the treatment of nerve injuries.
information from the central nervous system to
the effector organ.
The somatic nervous system comprises effer-
Supplementary Information The online version of this
ent neurons responsible for the conscious and vol-
chapter (https://doi.org/10.1007/978-3-030-82335-1_28)
contains supplementary material, which is available to untary control of skeletal muscles. In contrast, the
authorized users. autonomic (or visceral) nervous system controls
the visceral functions of the body, including the
A. Bolletta · E. Cigna (*) regulation of organs, glands, and vessels involved
Plastic Surgery Unit, Department of Translational in maintaining the homeostasis of the body.
Research and New Technologies in Medicine and
Surgery, University of Pisa, Pisa, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 429
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_28
430 A. Bolletta and E. Cigna
Peripheral nerves, composed of various combi- • Group A fibers, which present a thick myelin
nations of motor, sensory, and autonomic neurons, sheath, are the largest in diameter. As they are
can be classified into pure sensory, pure motor, or characterized by high conduction rates, they
mixed nerves, based on the different components. are involved in somatic muscle contraction,
From a microscopic perspective, peripheral proprioception, and fast pain sensation.
nerves are composed of unmyelinated or myelin- • Group B fibers transmit impulses at moderate
ated axons and Schwann cells. These latter cells speeds since they are lightly myelinated. They
play a vital role in maintaining and regenerating are preganglionic autonomic fibers.
the axons of the neurons in the peripheral ner- • Group C fibers are unmyelinated and present
vous system. They derive from the neural crest low conduction rates. They are involved in
and can be either myelinating or non-myelinating, slow pain sensation, thermoreceptors, and
affecting the degree of conduction velocity. postganglionic sympathetic transmission.
Myelinated axons are enveloped in multilami-
nated sheets of myelin provided by a single The figure represents the cross-sectional anat-
Schwann cell, whereas numerous unmyelinated omy of a peripheral nerve (Fig. 28.1).
axons are surrounded by a single Schwann cell- The epineurium is the connective tissue layer
derived membrane. that both encircles and runs between nerve fasci-
Nerve fibers constituting peripheral nerves cles. The primary function of the epineurium is to
can be classified according to fiber diameter and protect and nourish the nerve fascicles. The outer
the degree of conduction velocity (Table 28.1). layers of the epineurium form a sheath, termed
Epineurium
Perineurium
Endoneurium
Axon
Axonotmesis is a more severe form of injury recovery, as the entire population of regenerating
involving direct damage to the axons together axons is blocked. For this reason, a nerve graft
with focal demyelination while maintaining con- repair is indicated in such injuries. A Grade VI
tinuity of the connective tissues. Axonal damage lesion was later introduced by Mackinnon and
can be caused by a prolonged increase in perineu- Dellon to denote combinations of two or more
ral pressure. In this case, the segment of the axon injury patterns along the course of the damaged
located distal to the injury level undergoes nerve. This scenario represents the most chal-
Wallerian degeneration. In the meantime, proxi- lenging situation as it requires differentially
mally, the nerve fibers regenerate at a rate of treating the various nerve fascicles based on their
approximately 2.5 cm per month. The progress of degree of injury. In particular, it is necessary to
regeneration can be followed by the advancing identify and differentiate the fascicles that are
Tinel sign. normal or have the potential to recover from the
Neurotmesis occurs when nerve continuity is fourth- and fifth-grade component of the injury
interrupted both in terms of axons and all connec- pattern that requires reconstruction.
tive tissue elements. Surgical repair is necessary
for this type of nerve injury.
Sunderland later expanded Seddon’s classifi- Key Point (Table 28.3)
cation by distinguishing the extent of damage
affecting the connective tissues.
According to Sunderland’s classification,
Grade I and Grade V correspond to Seddon’s 28.4 Nerve Regeneration
neuropraxia and neurotmesis, respectively. In
contrast, axonotmesis is divided into Grades II– After an injury causing axonal transection, the
IV according to increasing amount of connective proximal axon undergoes traumatic degenera-
tissue damage. tion. In most cases, the area of degeneration of
In Grade II, axon damage is observed with no the proximal axon is located within the zone of
damage affecting the connective tissue. injury, or it extends proximally to the next node
Grade I and II injuries, due to the mild level of Ranvier. The axon distal to the site of the injury
of damage, are usually managed conservatively undergoes Wallerian degeneration, during which
with favorable outcomes, as demonstrated by myelin starts to deteriorate, and the axon becomes
clinical experience. A Grade III injury involves disorganized. Myelin and axonal debris are
damage to the endoneurium that prevents the phagocytized by Schwann cells.
regeneration of some injured axons. Management After Wallerian degeneration, the basal lamina
of these injuries involves surgical decompression of Schwann cells persists, as these cells create a
if the injury is localized in an area of entrapment. supportive environment for axon regeneration. A
In such cases, the outcome is better than that specialized motile apparatus is formed at the tip
obtained with a surgical repair or the use of a of the regenerating axon, the growth cone, which
graft. In Grade IV–V, damage to the perineu- releases protease to dissolve the matrix and clear
rium is present, with no potential for spontaneous its way to the target organ.
28 Nerve Surgery 433
Neurotrophic factors, such as the nerve growth first 3 weeks after the injury, but good results can
factor, aid in neurite survival, extension, and be obtained with repairs performed in the first
maturation. These macromolecules are present in 6 months after the injury.
denervated motor and sensory receptors, as well On the other hand, in cases of blunt injuries, it
as in Schwann cells. The nerve growth factor is wise to monitor the patient for signs of sponta-
guides axon regeneration and affects growth- neous recovery and delay surgical treatment.
cone morphology. Other factors involved in nerve Electrodiagnostic studies can be performed, as
regeneration are the neurite-promoting factors they will show signs of recovery before clinical
that promote neurite growth, like fibronectin as evidence of returning muscle function. Nerve
well as laminin, which accelerates axonal regen- recovery should proceed at a steady pace of
eration across a gap. Fibrinogen, a matrix- approximately 1 mm/day; hence, the recovery
forming precursor, is an essential substrate for time is strictly dependent on the injury level.
cell migration in nerve regeneration. Other fac- When patients show no signs of recovery on
tors involved are fibroblast growth factors, insu- electrodiagnostic studies or clinical examination
lin and insulin-like growth factor, electrical within 3–4 months after the injury, surgical
stimulation, and hormones such as thyroid hor- exploration and repair should be considered.
mone, estrogen, and testosterone [1]. Muscle tissue is sensitive to denervation. If
not reinnervated within approximately 12 months,
fat tissue replacement, atrophy, and muscle fibro-
28.5 Nerve Reconstruction sis will occur, leaving motor recovery unlikely.
For this reason, it is essential that motor axons
28.5.1 Timing reach the muscle end-plate within 1 year after
injury, and functional recovery is inversely pro-
When dealing with nerve injuries, the timing of portional to the time of muscle denervation.
nerve repair depends on many factors, including Regarding sensory nerves, the repair can be
not only the general condition of the patient, attempted any time after the injury, though
comorbidities, and associated injuries but also improved outcomes are achieved in earlier
the etiology and degree of injury. nerve repairs facilitated by correct nerve align-
Nerve repair performed within the first 72 h ment [4].
after injury is considered a primary repair. In
contrast, a repair performed up to 1 week after
injury is classified as delayed primary repair. Key Point
Secondary repair is a procedure performed more Primary repair is performed within the first
than 1 week following injury. Because nerve 72 h, delayed primary repair between 72 h
repair is not considered an emergency procedure, and 1 week, and secondary repair more
it can be delayed a few hours in order to be per- than 1 week after injury.
formed by a qualified surgeon during daytime
hours.
When a nerve transection is suspected after a
penetrating injury from a sharp object, early sur- 28.5.2 General Principles
gical exploration and reconstruction are recom-
mended, as it is still possible to stimulate the The main aim of nerve repair surgery is to design
distal stump of the nerve in the first 72 h, facilitat- the best possible connection between the proxi-
ing nerve alignment. After this time frame, the mal and distal stump to allow nerve regeneration.
surgeon must rely on knowledge of nerve topog- This outcome is possible, thanks to meticulous
raphy for nerve repair. When the nerve is com- microsurgical techniques performed under ade-
pletely transected, the best outcomes can be quate magnification and with the use of microsur-
achieved when repair is performed within the gical instruments and sutures.
434 A. Bolletta and E. Cigna
External Internal
epineurium epineurium
Epiperineurial suture
The needle is passed through the epineurium and 28.5.4.2 End-to-Side Sutures
the internal epineurium and tries to align the fas- End-to-side repair is being increasingly used by
cicles of both nerve stumps, without tying the many authors, representing an alternative when a
sutures too tightly, as this would cause the fasci- conventional end-to-end suture cannot be accom-
cles to twist within the epineurium. Two or three plished. This technique involves suturing the end of
interrupted sutures are added between the first a recipient nerve to the side of a donor nerve. An
two sutures on the anterior aspect. The nerve is epineurial window is created on the side of the
then rotated by pulling the lateral sutures so that donor nerve; usually, two or three 8-0 or 9-0 sutures
the posterior epineurium can be approximated are enough to approximate the nerve stump. In
and sutured. The advantage of this technique is order for this repairing technique to work, sensory
that it requires minimal manipulation of nerve branches must be connected to sensory nerves and
stumps, but it can be lacking in terms of precise motor branches to motor nerves, which can be
fascicle approximation. This technique is usually challenging in certain cases. Moreover, while col-
chosen for suturing nerves during primary repair lateral sprouting spontaneously occurs in sensory
or for nerve transfer. It finds its indication in nerves, in motor neurons, a proximal axonotmetic
proximal lesions, where considerable plexus for- injury must be performed on the donor nerve to
mation is found between the fascicles. obtain regenerative sprouting [6].
Perineurial Suture
Pearls and Pitfalls
For a perineurial suture, the epineurium is
The epineurial suture causes minimal
removed from both ends of the nerve stump, and
manipulation of nerve stumps, but does not
fascicles are meticulously dissected with micro-
allow precise fascicle approximation. The
surgery scissors. After orienting and matching
perineurial suture is highly accurate but
each fascicle between both stumps, each single
requires fascicle manipulation. The epiper-
fascicle is sutured with 10-0 nylon. The needle is
ineurial combined suture presents the
passed through the perineurium, close to its edge,
advantages of both abovementioned
and the repair is completed by placing three or
techniques.
four sutures. This technique ensures a high level
of accuracy in the juxtaposition of the nerve
stumps, but it requires greater manipulation of
the nerve fascicles. There is also a risk of inac- 28.5.5 Nerve Grafts
curate fascicle matching, compromising the out-
come. In distal repair, this approach can enhance 28.5.5.1 Autograft
outcomes due to its accuracy. In cases where a nerve gap exists and it is not
possible to perform a direct suture, such as inju-
Epiperineurial Combined Suture ries involving loss of substance or nerve stump
The epiperineurial combined suture technique retraction and neuroma formation, a nerve graft
allows for a more accurate adaptation of the is considered the gold standard procedure
peripheral fascicles within the epineurium by (Fig. 28.4). Usually, nerve grafting is not per-
combining the advantages of both previously formed immediately but is delayed for approxi-
mentioned techniques. The 8-0 or 9-0 nylon mately 3 weeks after the trauma in order to
sutures are passed through the epineurium and determine the extent of the injury. Nevertheless,
perineurium of peripheral fascicles with the same early nerve grafting can be performed when early
pass of the needle and then tied. In this approach, soft tissue coverage is required, or when a sec-
suturing is performed in a circumferential order, ondary procedure is expected to be particularly
as this allows adapting the remaining fascicles difficult. In this case, the proximal and distal
more accurately. nerve stumps should be accurately trimmed to
436 A. Bolletta and E. Cigna
Grafts
Key Point
The nerve graft is considered the gold stan-
dard procedure in cases where a nerve gap Fig. 28.6 Vascularized nerve graft for ulnar nerve
does not allow direct suture. The nerve reconstruction
graft facilitates axonal regeneration and
should align motor fascicles with motor
fascicles and sensory fascicles with sen- vascular network. The divided graft is then anas-
sory fascicles. tomosed to the recipient nerve [8].
example, across a joint, in order to restore its necting the superior aspect of the tragus to the
function. Muscle transfer can be performed using angle of the jaw. The nerve initially divides into
a muscle from a different body area, which needs two major trunks, which then further divide into
to be transferred as a free flap, thereby perform- five major branches: temporal, zygomatic, buc-
ing a distal revascularization and nerve repair. cal, marginal mandibular, and cervical. As they
A key element in approaching this procedure travel distally to the muscles they innervate, the
is understanding muscle physiology. Since skel- branches of the facial nerve become more
etal muscle properties highly rely on the restora- vulnerable.
tion of the length-tension relationship, it is Facial nerve palsy is a condition in which the
important to set the muscle resting tension appro- function of the facial nerve is partially or com-
priately in order to maximize muscle contraction pletely lost. It can be congenital or acquired.
forces. Bell’s palsy is a frequent form of acute idio-
The ideal muscle for a transfer should be pow- pathic facial paralysis, accounting for 85% of
erful and long enough to accomplish the desired all cases of facial paralysis. It is unilateral and,
function, but it must also present enough tendon in most patients, has a spontaneous resolution,
and fascia to support origin and insertion attach- although some patients may experience lasting
ments. Regarding the neurovascular anatomy of motor deficits. In other cases, a specific cause,
the transplanted muscle, it should have a domi- such as infection, trauma, or metabolic disor-
nant vascular pedicle with a single motor nervous ders, can be identified. Iatrogenic injury to the
supply. Moreover, the ideal donor site should facial nerve is possible during procedures such
cause limited functional loss. as parotidectomy, skull base surgery, and
Numerous muscles meet these criteria and are facelift.
therefore used in clinical practice for functional As previously described, neuropraxia is the
muscle transfers, including the gracilis, latissi- mildest form of nerve injury and, in most cases,
mus dorsi, tensor fascia latae, rectus femoris, resolves within 3–6 months. Electrophysiologic
medial gastrocnemius, serratus anterior, and pec- studies performed in the early stages after injury
toralis major and minor [12]. can help distinguish neuropraxia from other
forms of nerve injury. In these cases, watchful
waiting for 6 months is recommended before
Key Point
considering surgical treatment [13].
Tendon transfers and free functional mus-
cle transfers allow function restoration
when nerve regeneration is not achievable.
28.7.1 T
reatment of Facial Nerve
Injury
28.7 Facial Nerve Reconstruction After severe forms of facial nerve injury and sub-
sequent paralysis, further treatment is indicated,
The facial nerve is composed of motor, sensory, and different approaches may be used to improve
and parasympathetic fibers. Its major functions patient appearance.
include motor supply to facial muscles, parasym- The use of dynamic reanimation techniques
pathetic secretomotor supply to salivary and lac- aims at directly repairing the facial nerve or
rimal glands, taste sensation from the anterior restoring dynamic movement, whereas static
two-thirds of the tongue, and cutaneous sensa- treatment techniques do not restore dynamic
tions from the external auditory meatus. movement but still improve patient deficits and
Regarding its course, the facial nerve exits appearance. In clinical practice, a combination of
the skull at the stylomastoid foramen and enters these techniques is often used in a multimodal
the parotid gland at the midpoint of the line con- approach [14].
440 A. Bolletta and E. Cigna
28.7.1.1 Facial Nerve Repair mimetic motion and emotional expression. Since
Primary strategies for facial nerve repair include the technique requires a significant amount of
end-to-end repair, nerve grafting, and nerve time for axons to reach the target, atrophy of the
transfer. denervated muscles is a risk. For this reason, a
End-to-end repair is performed by directly temporary anastomosis can be created, with
suturing the severed ends of a nerve in a tension- motor nerves (hypoglossal or masseteric nerves)
free manner. This technique is indicated if the providing a motor input while reinnervation from
nerve is severed during a surgical procedure. In the contralateral facial nerve is achieved (baby-
this case, it should be performed immediately or sitter procedure).
within 72 h. In terms of outcomes, early repair is consis-
Nerve grafting is appropriate if the nerve tently related to better results than late repair.
injury results in a substantial gap between the The same applies to nerve grafts or nerve trans-
two ends of the nerve. When multiple branches of fer procedures performed within 6 months after
the facial nerve are damaged, it is possible to per- injury [16].
form multiple separate grafts (Fig. 28.8).
Alternatively, biological or synthetic conduits
Tips and Tricks
can be used in these cases.
End-to-end suture repair should be per-
In nerve transfer approaches, the nerves most
formed immediately or within 72 h.
frequently used are the hypoglossal nerve and the
Multiple separate nerve grafts can be
masseteric nerve. The hypoglossal nerve is com-
used to treat nerve gaps of multiple facial
monly used for immediate reconstruction of the
nerve branches.
proximal facial nerve during tumor extirpation
The hypoglossal and masseteric nerves
[15]. Masseteric nerve transfer is characterized
are commonly used as donor nerves for
by easy dissection, low donor site morbidity, and
facial reanimation.
fast onset of movement (approximately 6 months
The cross-face technique involves posi-
after surgery). The contralateral facial nerve is
tioning a nerve graft to connect the injured
also used for motor reinnervation, a technique
facial nerve to the contralateral nerve.
that requires nerve grafts to be passed across the
face and attached to branches of the injured facial
nerve (cross-face). This approach offers the most
natural results as it allows for spontaneous 28.7.1.2 Muscle Transfer
for Reanimation
Dynamic facial reanimation in patients affected
by long-standing facial paralysis may be achieved
using regional or free muscle transfer, as in these
patients, facial muscles would not provide useful
function after reinnervation.
The temporalis muscle may be transferred to
the upper half of the lower lip, allowing for eleva-
tion of the oral commissure. This option is indi-
cated in patients who want an immediate solution
with a short recovery time. Free muscle transfer
involves transplanting a muscle segment, which
is then reinnervated using an ipsilateral motor
nerve (masseteric nerve) or the contralateral
facial nerve via a cross-face graft. The muscles
Fig. 28.8 Split nerve graft used to repair nerve gaps of most frequently used for this purpose are the
multiple facial nerve branches gracilis, the latissimus dorsi, and the pectoralis
28 Nerve Surgery 441
minor. The gracilis muscle is the most commonly demarcate and ensure a safer and more effective
used as it presents numerous advantages, such as repair. When a nerve gap is found, it can be
fusiform shape, powerful contraction, and low addressed with the abovementioned techniques,
donor site morbidity [17]. such as nerve grafts or conduits. In addition, a
nerve transfer can be performed to accelerate
28.7.1.3 Static Reconstruction recovery in high-level injuries by decreasing the
When facial reanimation is contraindicated or distance between the site of the nerve repair and
not achievable, such as in elderly patients with the motor end-plate. Indications for nerve trans-
comorbidities, several static techniques can be fers in the treatment of upper extremity nerve
used. The aim of these procedures is to correct reconstruction are many and include proximal
functional disability and restore facial symme- brachial plexus injuries, in which grafting is not
try at rest. Brow lift, upper eyelid loading, and possible, but also proximal nerve injuries requir-
tarsorrhaphy may be used to address visual ing long distances for reinnervation of distal
issues and protect the cornea. Other static pro- targets. Additional indications include severely
cedures, including facial muscle plication, facial scarred regions, patients with delayed presenta-
sling suspension, and neuromodulator inject- tion, and segmental nerve loss related to major
ables, are used to restore symmetry and reduce trauma. Other reconstructive options are repre-
drooling [18]. sented by tendon transfers and free functional
muscle transfers. While tendon transfer relies on
the presence of functioning muscles, a free func-
28.8 Peripheral Nerve tional muscle transfer can be performed if there is
Reconstruction a viable donor nerve and an adequate recipient
vessel.
28.8.1 Brachial Plexus Pan-plexus injuries present the greatest vari-
and Upper Limb ability in reconstructive approaches. The mini-
mal surgical goal would be for shoulder stability
While brachial plexus injuries are often devastat- and elbow flexion, though newer techniques may
ing, with life-altering consequences, injuries be able to offer some recovery of rudimentary
affecting the major nerves of the upper limb grasp. In these complex cases, reconstructive
result in a variety of different conditions, mainly options largely depend on the number of remain-
dependent on the nerve damage and the level of ing viable spinal nerves [19–21].
injury.
Immediate surgical treatment is performed
when, according to the type of injury, physical 28.8.2 Lower Limb
examination, and electrodiagnostic and imaging
studies, spontaneous recovery is not possible. Nerve lesions of the lower limb are less fre-
Otherwise, a delayed procedure can be consid- quently discussed, even though they are rela-
ered within 6–12 months in the absence of clini- tively common in orthopedic practice. Injuries
cal and electrodiagnostic evidence of recovery. related to traction or stretching of the nerves are
For example, immediate exploration and pri- common in work or road accident traumas, as
mary repair are indicated in sharp open injuries well as those due to skeletal fractures.
with acute nerve deficits. In these cases, when- Furthermore, lower extremity nerve injuries are
ever possible, a direct end-to-end suture of nerve also related to knee sprain or hip dislocation.
stumps is advisable if achievable in a tension-free Even though most traumatic and iatrogenic
manner. In the case of a blunt open injury with nerve injuries of the lower limb are in continu-
nerve rupture, the stumps of the nerve should be ity, they frequently involve axonotmesis and
accurately tagged and a delayed repair performed should not be assumed to be simple neuroprax-
3–4 weeks later to allow the zone of injury to ias. For this reason, a thorough history and
442 A. Bolletta and E. Cigna
physical examination, together with serial elec- Many different measurement instruments can
trodiagnostic studies and advanced imaging, be used in peripheral nerve evaluation, including
should be used to assess nerve injury in these sensory and motor tests, pain and discomfort
cases. Outcomes of nerve recovery in the lower assessments, neurophysiological examination,
limb vary widely, even between operative and and imaging.
nonoperative treatments. Moreover, while the Sensory tests are employed to evaluate sen-
recovery of the femoral and tibial nerve is often sory acuity. The Semmes-Weinstein monofilament
satisfactory, for the sciatic and common pero- test is used to assess the perception of cutaneous
neal nerve around the knee, outcomes are disap- pressure threshold, reflecting reinnervation of
pointing. In fact, operative repair of the femoral peripheral targets. The two-point discrimination
and tibial nerve has shown superior results com- test is an established assessment tool for innerva-
pared to the sciatic and common peroneal nerve, tion density, aiming at determining the smallest
in which neurolysis is related to better prognosis distance between two points that still results in
than repair or grafting. In general, as previously the perception of two distinct stimuli. Other func-
mentioned for the upper limb, sharp lacerations tional sensory tests include vibration and
require early surgical exploration. However, temperature perception, shape and texture identi-
when severe nerve contusion is involved, a delay fication, and thickness discrimination.
of several weeks is suggested to allow demarca- Evaluation of motor function is based on
tion of the area of injury. In the case of stretch qualitative, semi-quantitative, and quantitative
injuries or blunt trauma, observation is sug- examinations.
gested, together with serial physical examina- Qualitative evaluation is performed by
tion and electrodiagnostic and imaging studies. observing muscle volume and tone. Manual
When no signs of recovery are observed after muscle testing is a semi-quantitative evaluation
2–5 months, nerve exploration is necessary, and used to assess motor innervation by way of a
nerve damage can be addressed with neurolysis, muscle strength grading system. Quantitative
repair, or grafting, according to the situation examinations involve using dynamometers that
[22, 23]. measure muscle strength (e.g., hand-held
dynamometer).
In contrast, the evaluation of pain is always
28.9 Assessment of Peripheral based on self-report by patients. Moreover,
Nerve Function assessing the impact of pain on the quality of life
is essential.
Evaluation of peripheral nerve function after Neurophysiological examinations include
injury and outcome assessment following treat- electroneurography (ENG) and electromyogra-
ment remains a complex process for therapists phy (EMG). These studies, used to evaluate the
and surgeons. A combination of tests is required electrical activity of nerves and muscles, provide
to aid clinical diagnosis, assess surgical repair, valuable information on the location and patho-
and track rehabilitation progress. physiology of peripheral nerve lesions.
During clinical evaluation, the Hoffman-Tinel Recent developments in the field of periph-
sign, more commonly known as the Tinel sign, is eral nerve imaging have extended the capabili-
a simple yet valuable tool. It is defined as the ties of imaging modalities to assist in the
“pins and needle feeling” provoked by tapping on diagnosis and treatment of patients with periph-
a nerve, with resulting paresthesia in the corre- eral nerve injuries. Methods such as MRI and
sponding distal distribution of an injured periph- ultrasound are capable of assessing nerve struc-
eral nerve. The Tinel sign is commonly used as ture and function following injury and relating
an indication of peripheral nerve compression or the state of the nerve to electrophysiological
regeneration. analysis [24].
28 Nerve Surgery 443
13. Condie D, Tolkachjov SN. Facial nerve injury and 20. Boyd KU, Nimigan AS, Mackinnon SE. Nerve recon-
repair: a practical review for cutaneous surgery. struction in the hand and upper extremity. Clin Plast
Dermatol Surg. 2019;45(3):340–57. Surg. 2011;38(4):643–60.
14. Hadlock TA, Greenfield LJ, Wernick-Robinson 21. Felici N, Cannatà C, Cigna E, Sorvillo V, Del Bene
M, Cheney ML. Multimodality approach to man- M. Contralateral spinal accessory nerve: a suitable
agement of the paralyzed face. Laryngoscope. “new” donor nerve for heterotopic nerve transfer in
2006;116(8):1385–9. total brachial plexus palsy. Handchir Mikrochir Plast
15. Dalla Toffola E, Pavese C, Cecini M, Petrucci Chir. 2012;44(2):80–3.
L, Ricotti S, Bejor M, et al. Hypoglossal-facial 22. Ray WZ, Mackinnon SE. Nerve problems in the lower
nerve anastomosis and rehabilitation in patients extremity. Foot Ankle Clin. 2011;16(2):243–54.
with complete facial palsy: cohort study of 30 23. Immerman I, Price AE, Alfonso I, Grossman
patients followed up for three years. Funct Neurol. JAI. Lower extremity nerve trauma. Bull Hosp Jt Dis
2014;29(3):183–7. (2013). 2014;72(1):43–52.
16. Terzis JK, Konofaos P. Experience with 60 adult 24. Wang Y, Sunitha M, Chung KC. How to measure
patients with facial paralysis secondary to tumor extir- outcomes of peripheral nerve surgery. Hand Clin.
pation. Plast Reconstr Surg. 2012;130(1):51e–66e. 2013;29(3):349–61.
17. Bianchi B, Ferri A, Sesenna E. Facial reanimation 25. Aman M, Sporer ME, Gstoettner C, Prahm C, Hofer
after nerve sacrifice in the treatment of head and C, Mayr W, et al. Bionic hand as artificial organ:
neck cancer. Curr Opin Otolaryngol Head Neck Surg. current status and future perspectives. Artif Organs.
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18. Ibrahim AMS, Rabie AN, Kim PS, Medina M,
Upton J, Lee BT, et al. Static treatment modalities
in facial paralysis: a review. J Reconstr Microsurg. Further Reading
2013;29(4):223–32.
19. Noland SS, Bishop AT, Spinner RJ, Shin AY. Adult Mackinnon SE. Nerve surgery. Thieme Medical
traumatic brachial plexus injuries. J Am Acad Orthop Publishers, Inc.; © 2015.
Surg. 2019;27(19):705–16.
Gender-Affirming Surgery
29
Samyd S. Bustos, Valeria P. Bustos, Pedro Ciudad,
and Oscar J. Manrique
29.1 Terminology
Key Point
Based on the Standards of Care for the Health of Key definitions based on the WPATH
Transsexual, Transgender, and Gender- Standards of Care for the Health of
Nonconforming People (SOC), Version 7, pro- Transsexual, Transgender, and Gender-
vided by the World Professional Association for Nonconforming People, 7th version:
Transgender Health (WPATH), treatment options
for gender dysphoria include psychotherapy, • Cisgender: adjective to describe indi-
changes in gender expression and role, hormonal viduals whose sense of personal identity
or endocrine therapy, and gender-affirming sur- and gender correspond with their sex
gery (GAS). A multidisciplinary approach assigned at birth.
including various treatment options is paramount • Gender: range of psychological and cul-
for the comprehensive management of gender tural characteristics associated with bio-
dysphoria in TGNC individuals. In this chapter, logical sex. It is a sociological and
we provide an overview of gender-affirming sur- psychological concept, not a biological
gical procedures (Table 29.1). term.
• Gender dysphoria: distress that is caused
by a discrepancy between a person’s
Table 29.1 Gender-affirming surgeries gender identity and that person’s sex
Masculinization assigned at birth (and the associated
surgery Feminization surgery gender role and/or primary and second-
Face Facial Facial feminization
masculinization Thyroid
ary sex characteristics).
Liposuction chondroplasty • Gender identity: a person’s intrinsic
Lipofilling Hairline sense of being male, female, or an alter-
Voice modification reconstruction native gender.
surgery Voice modification
surgery
• Gender-nonconforming: adjective to
Chest Subcutaneous Augmentation describe individuals whose gender iden-
mastectomy mammoplasty tity, role, or expression differs from
Chest-wall Lipofilling what is normative for their assigned sex
contouring
in a given culture and historical period.
Pectoral implants
Genitalia Hysterectomy Orchiectomy • Gender role or expression: characteris-
Salpingo- Penectomy tics in personality, appearance, and
oophorectomy Vaginoplasty + behavior that in a given culture and his-
Vaginectomy clitorolabiaplasty torical period are designated as mascu-
Clitoral release Vulvoplasty +
Metoidioplasty ± clitorolabiaplasty line or feminine (i.e., more typical of the
urethral lengthening Gluteal augmentation male or female social role).
Phalloplasty ± Waist lipoplasty • Sex: sex is assigned at birth as male or
urethral lengthening female, usually based on the appearance
Scrotoplasty
Testicular prosthesis of the external genitalia. When the
placement external genitalia are ambiguous, other
Penile prosthesis components of sex (internal genitalia,
placement
29 Gender-Affirming Surgery 447
Table 29.2 Eligibility criteria based on the Standard of Care of the World Professional Association for Transgender
Health
Referral lettera Hormonal treatment Social transition
Facial surgery NS NS NS
Chest surgery
Mastectomy 1 No No
Augmentation mammoplasty 1 Noc No
Genital surgery
Hysterectomy/salpingo-oophorectomy or orchiectomy 2 1 yr No
Metoidioplasty 2 1 yr 1 yr
Phalloplasty or vaginoplasty 2 1 yrb 1 yr
Other surgical procedures No No No
NS criteria not stated, yr year
a
Referral letter must be from a mental health professional. If two letters are required, they must be from two different
professionals
b
Only if hormone therapy criteria are made, and no contraindications are present
c
Although not an explicit criterion, it is recommended that transfeminine patients undergo feminizing hormone therapy
(minimum 12 months) prior to gender-affirming augmentation mammoplasty
448 S. S. Bustos et al.
a b c
risk donor site morbidity [11]. This proce- this surgery. The most common donor site
dure is also used to repair strictures, complication is regrafting of the arm [33].
fistulas, and scrotoplasty complications On the other hand, the majority of compli-
[11]. Major drawbacks are the inability to cations are related to urethral reconstruc-
have an intrinsic sexual function, hair tion or penile prosthesis placement [11,
depilation requirement, and skin graft 33]. Other important disadvantages are the
donor site coverage [11]. requirement of hair depilation, skin color
• Free Flap Phalloplasty mismatch, no intrinsic sexual function, and
Free flaps allow the surgeons to perform long and complex surgery that requires
microvascular anastomosis between donor expertise [11]. However, it has high overall
and recipient vessels. A wide variety of tissue satisfaction [11, 33] [11, 33, 35].
options are available for neo-phallus recon- –– Fibula Flap Phalloplasty
struction. The most common free flap phallo- The fibula flap phalloplasty is an osteo-
plasties are the radial forearm flap phalloplasty, cutaneous free flap phalloplasty. This flap
fibula flap phalloplasty, and latissimus dorsi is based off the peroneal vessels.
flap phalloplasty [11]. The anterolateral thigh Neurorrhaphy can be performed with the
flap can be also used as a free flap for phallo- lateral or posterior cutaneous and the ilio-
plasty depending on the pedicle length and inguinal or dorsal clitoral nerves, respec-
tension. tively, to achieve tactile and erogenous
–– Radial Forearm Flap Phalloplasty sensation. Long-term follow-up shows
The radial forearm flap phalloplasty is minimal bone resorption [11, 37]. These
the most common type of flap-based phal- flaps provide a permanent rigid neo-phallus
loplasty [11]. This flap is based off the with minimal quality of life changes [33].
radial artery. This thin and pliable full- Major advantages are the achievement of
thickness flap makes it an ideal option for anatomically sized neo-phallus, adequate
the formation of the neo-phallus and ure- bulk under clothes, robust vascular pedicle,
thra using the “tube-within-tube” technique well-hidden donor site, and possibility of
[33–36]. Neo-phallus length can range penetration without IPP [11]. Up to 90% of
from 7.5 to 16 cm [33]. The medial and lat- patients are able to achieve micturition in
eral antebrachial cutaneous nerves are usu- the standing position, and 51.7% are able
ally preserved to perform neurorrhaphy to have penetrative sexual intercourse [33].
with the ilioinguinal nerve and dorsal nerve Major complications of this approach
to achieve erogenous and tactile sensation include urethral complications with
[34]. The Allen test should be performed prefabricated neo-urethra, such as urethral
preoperatively to confirm adequate perfu- stricture and stenosis in 24.6% cases [33].
sion of the non-dominant hand [34]. Urethral prelamination is necessary due to
Major advantages of this technique are the rigidity of the flap [11]. Other draw-
anatomically sized neo-phallus, normal- backs are no intrinsic sexual function, poor
appearing bulk under clothes, robust vascu- tactile and erogenous sensation, depilation
lar pedicle, penetrative sex with IPP, and requirements, risk of leg/ankle instability,
low complication rates [11]. In addition, leg splinting and physical therapy, and skin
the radial forearm flap can create both the color mismatch [11].
neo-phallus and urethra. The major and –– Latissimus Dorsi Flap Phalloplasty
most important drawback is the donor site The latissimus dorsi flap phalloplasty is
morbidity. The forearm defect is large, a musculocutaneous flap designed for the
unique, and visible, usually requiring split creation of the neo-phallus. This flap is
or full-thickness skin grafts [11]. This based off the thoracodorsal neurovascular
donor site morbidity is pathognomonic for bundle [33, 38]. In order to achieve volun-
29 Gender-Affirming Surgery 453
Table 29.3 Clinical outcomes after genital-affirming surgery in transmasculine patients [33]
Technique/flap Neo-phallus Tactile Urinary function (voiding Sexual function (erections/
type length (cm) sensation (%) while standing) (%) intercourse) (%)
Metoidioplasty 4–10 100 94.1 100
Anterolateral 10 75 66.7 60
thigh
Abdominal-based 3.7–16 75 37.3 19.6
Groin-based 7.5–15 100 100 100
Gracilis 4–15 100 100 100
Fibula 100 90 51.7
Radial forearm 7.5–14 98.4 97.5 21.7
Latissimus dorsi 7–17 100 100 14.8
tary contraction of the neo-phallus, a neu- achieving scrotal anatomy [11, 39]. This sur-
rorrhaphy can be performed between the gical procedure consists of joining the labial
thoracodorsal motor nerve and a branch of majora in the midline to achieve masculine
the obturator motor nerve [11, 38]. The scrotal anatomy. Then, the superior-based
muscle contraction leads to an “erection” labial flaps are raised and rotated medially
by stiffness, widening, and shortening of 180° before approximating labial majora folds
the neo-phallus that permits sexual inter- to reach cis-male anatomic position [39]. The
course, which simulates erection in 85–92% labia majora provides sufficient volume to
[11, 38]. However, only 14.8–42% reported neo-scrotum; however, in occasions, the use
having penetrative intercourse [11, 33, 38]. of a gracilis flap and/or the placement of sili-
The major advantages of this flap are the cone testicular prostheses is needed to aug-
anatomically sized neo-phallus, bulk under ment the volume [11].
clothes, long, robust and reliable vascular • Testicular Prostheses Implantation
pedicle, hidden donor site with minimal This technique is performed as a secondary
functional loss, and closure by primary procedure. This surgical technique consists of
intention [11]. Up to 83% of patients performing a mid-scrotal vertical incision or a
reported donor site morbidity as acceptable horizontal incision at the scroto-phallic transi-
[38]. Major drawbacks are no intrinsic sex- tion [40]. After two separate pockets are cre-
ual function, suboptimal sensation, and ated, implanted testicular prostheses are
necessity of electrostimulation to promote selected depending on the neo-scrotal size
muscle contraction, and tonic muscle con- [40]. Patients are recommended to not place
traction is impractical for penetration [11]. any pressure to the neo-scrotum for at least
The most common complications are fis- 4 weeks [40].
tula (13.2%) and hematoma (13.2%) [33]. Postoperative complications have been
Most patients reported to be satisfied with described to be related to infection, extrusion,
the results [33] (Table 29.3). discomfort, prosthesis leakage, or urethral
problems [40]. Up to 20.8% require explanta-
29.3.3.5 Additional Procedures tion of one or both prostheses due to postop-
• Scrotoplasty erative complications [40]. Smoking is an
Scrotoplasty is a surgical procedure that important risk factor for infection and prothe-
can be performed at the time of the metoidio- sis explanation [40].
plasty or phalloplasty [11]. Since labia majora • Penile Prostheses
comes from the same embryologic structure Penile prostheses are placed in patients that
and are anatomic equivalents, they have simi- desire a neo-phallus rigid enough for penetra-
lar skin color, hair, texture, and sensation, tive sex [11]. Flap-based phalloplasties per-
making this tissue an ideal candidate for formed with autologous bone or cartilage do
454 S. S. Bustos et al.
a b
Nose narrowed
Nose narrowed
Before and after facial surgery (front view) Before andd after facial surgery (side view)
c d
Inside mouth
Coronal incision
© MAYO CLINIC
Endoscopic incisions © MAYO CLINIC
Hairline incision
Under chin
Fig. 29.2 Facial feminization surgery for transfeminine (c) and in the lower third of the face (d) (Used with per-
individuals. Main surgical outcomes in facial feminization mission of Mayo Foundation for medical Education and
from a frontal view (a) and a lateral view (b). Different Research, all rights reserved)
incision locations for facial feminization in the upper third
Fig. 29.3 Gender-affirming augmentation mammoplasty of Mayo Foundation for medical Education and Research,
depicting implant (or tissue expander) positioning in the all rights reserved)
prepectoral (subglandural) plane (Used with permission
29 Gender-Affirming Surgery 457
Key Point
Orchiectomy is a relatively straightforward
procedure that can be performed prior to
Fig. 29.4 Depiction of the anatomy before (a) and after
vaginoplasty as a separate procedure or at
(b) penile inversion vaginoplasty (Used with permission
the same time of the vaginoplasty (usually of Mayo Foundation for medical Education and Research,
preferred). all rights reserved)
Take-Home Messages
References
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V. Cervelli (*) · G. Storti The first instances of fat grafts trace back to the
Plastic and Reconstructive Surgery, Department of end of the nineteenth century and the beginning
Surgical Sciences, University of Rome “Tor Vergata”, of the twentieth century. These initial attempts
Rome, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 463
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_30
464 V. Cervelli and G. Storti
entailed an autologous transfer of en bloc adipose mediocre results of this process in terms of
tissue portions from one spot to another. engraftment not only implied the need for impor-
The first description of fat transfer dates back tant hypercorrection but also proved the tech-
to 1893 when Gustav Neuber, a German surgeon, nique to be hardly applicable.
harvested some fat tissue from the arm and trans- In 1986, Ellenbogen understood that the fat
planted it to the lower orbit to release adherent particle’s dimension was one of the most critical
scars derived from osteomyelitis and to correct parameters to consider when performing a fat
volume loss. Even though the initial results were transfer. The fat particle’s optimal size is crucial
good, Neuber experienced quite soon high to allow a correct exchange of nutrients between
resorption rates. the recipient site and the graft.
In 1895, Vincent Czerny, another German sur- He used to transplant the so-called fat pearls,
geon used a fist-sized lipoma removed from the which were fat particles of 4 or 6 mm that he used
gluteal area to fill in the defect left by a partial in several aesthetic conditions, like acne scars or
mastectomy. sunken eyes. Despite initial promising results,
From Berlin, Eugene Holländer described in this technique failed in assuring long-term reten-
1912 the fat infiltration in two patients affected tion of the fat.
by lipoatrophy of the face, also providing photo- Later trials also showed that the oil coming
graphic documentation. from the broken adipocytes, blood, and infiltra-
Parallelly, in 1910, Lexer, who was a maxil- tion liquids hindered the graft survival and, thus,
lofacial surgeon, described the fat transfer as a its durability.
possibility to treat aging faces and in 1919 pub- By the end of the 1990s, Sydney Coleman
lished a book in two volumes where he described introduced, for the first time, a fat-processing
the use of fat grafting for multiple reconstruc- standardized procedure through which it was
tive purposes, including traumas, hemifacial possible to obtain reliable results [2]. Coleman’s
microsomia, tenolysis, and treatment of knee technique regarding the so-called lipostructure
ankylosis. was based on fundamental principles to achieve a
Such a wide use of fat transfer suggests that long-lasting result.
the adipose tissue’s regenerative and reparative This technique can be summarized with three
possibilities have been known since the begin- innovations in particular:
ning, at least in part.
In 1920, at the end of World War I, Sir Harold –– Fat centrifugation at 3000 rpm for 3 min
Gillies reported good results in treating with fat –– The infiltration of small quantities of fat
parcels veterans who had severe facial wounds. –– Fat infiltration on multiple layers
In 1926, Miller was the first to write down a
detailed monograph about injecting fat via can- Coleman’s centrifugation leads to the separa-
nulas to exploit it. tion of three essential layers within the lipoaspi-
Nonetheless, ever since the first trial, fat grafts rate (Fig. 30.1).
presented evident significant complications. The The most superficial level is composed of oil
reabsorption of the grafted fat after just a few and dead or broken adipocytes; the intermediate
months, in particular, caused unpredictable one is composed of vital adipocytes and other
results and the formation of oily cysts due to fat cells (including adipocyte-derived stem/stromal
necrosis [1]. cells); finally, the lower one is mainly composed
Thanks to the perfected liposuction techniques of blood and infiltration liquid. Coleman’s inno-
developed by Illouz and Fournier in the 1980s, it vation consisted of injecting only the intermedi-
was possible to gather considerable quantities of ate level made of living cells. Moreover, the
adipose tissue that could eventually be used for infiltration of small amounts of fat on multiple
fat transfer. Illouz and Fournier also attempted to layers granted an optimum contact between the
inject the non-processed lipoaspirate, but the receiving site and the purified fat graft, leading to
30 Regenerative Surgery 465
a b c
Fig. 30.1 Different steps of fat processing according to Centrifugation allows the separation of fat into three lay-
the Coleman technique. In (a), we can see the lipoaspirate, ers from which only the purified fat will be injected (c)
which is centrifuged at 1200 g (3000 rpm) per 3 min (b).
better graft perfusion, significantly more efficient mum healing by developing an efficient
engraftment, and long-term stable results. neovascularization and a biological niche apt to
It was observed that in these conditions, fat restitutio ad integrum was crucial.
grafting not only presented filling effects but The use of ADSCs and, more in general, of all
improved scar conditions and, more in general, the fat grafting-based techniques had extremely
tissue and skin conditions. positive implications, especially for treating
It was not until 2001 that Patricia Zuk and complex wounds, burns, and areas undergoing
her colleagues noted for the first time the pres- radiotherapy.
ence, within the adipose tissue, of mesenchymal- The term “regenerative medicine” (and sur-
derived cells with stem potential, then gery) was used for the first time in an article pub-
denominated adipose-derived stem/stromal lished by Rigotti in 2007, which regarded
cells (ADSC) [3]. radionecrosis areas located in the thoracic region
This innovative discovery revolutionized fat and treated with fat grafting [4]. In these patients,
grafting in both reconstructive and aesthetic sur- ADSCs were able to fix the damages caused by
gery. It was particularly emphasized that ADSCs radiotherapy and allowed injured areas to heal.
could proliferate in the recipient site; differenti- Concurrent to the discoveries concerning
ate into mature cells such as adipocytes, osteo- ADSCs, regenerative surgery could benefit from
blasts, or chondrocytes; and secrete growth other new techniques and products. In particular,
factors, at last, hence promoting cell proliferation by the end of the twentieth century, it was noted
and neoangiogenesis in the recipient site. that the use of platelet-rich plasma (PRP)
These essential effects were also exploited in improved fat engraftment and aided in the cre-
plastic reconstructive surgery fields where recre- ation of a pro-regenerative environment [5]. The
ating a microenvironment able to promote opti- latter proved useful for some aesthetic surgery
466 V. Cervelli and G. Storti
procedures as well, such as hair loss treatment insulin) and other innate mechanisms of the
and the amelioration of skin elasticity. organism, like inflammation or tissue repair.
With time, it became evident that, in order to Adipocytes and other cell populations coming
obtain optimum healing as well as a functional from the adipose tissue form a net of endocrine
and mechanical recovery of damaged tissues, it and paracrine exchanges, so complicated and
was essential to not only stimulate both cell pro- functionally organized that the adipose tissue
liferation and differentiation but also promote a itself could very well be considered an actual
three-dimensional structural organization, simi- organ.
lar to that of the initial tissue and the extracellular Despite adipose tissue being mostly constituted
matrix (ECM) in it. This notion is especially true by adipocytes in volumetric terms, it also contains
for tissues like bone tissue, which needs both cor- many other cell populations that are more in num-
rect cell differentiation and a precise spatial orga- ber even if holding less volume. They include peri-
nization and definite mechanical properties to cytes, endothelial cells, mononuclear cells,
correctly function, especially in load-bearing lymphocytes, and, of course, ADSCs. All of them
bones. are enclosed in the perivascular ECM. It is possi-
For this reason, by the end of the 1980s, it was ble to isolate them from the rest of the lipoaspirate
necessary to create new materials and three- by breaking down the ECM net, either through
dimensional constructs (i.e., the so-called scaf- enzymatic or mechanical means. The final product
folds), able to mimic the physiologically existent is called stromal vascular fraction (SVF), and it is
ECM and guide cell proliferation in order to form naturally made of different kinds of cells, 20% of
structures similar to the original ones. Scaffolds, them being ADSCs. SVF, once cultivated in vitro
either biologically or chemically derived, and through multiple steps, enables the isolation of
their eventual combination with cells and differ- ADSCs. For this reason, it is possible to talk about
entiating agents laid the foundations for tissue ADSCs in the strict sense only after all of these
engineering. procedures.
All the techniques listed in this paragraph ADSCs belong to a broader category of mes-
have been used both alone and combined, and enchymal cells with stem phenotype, called mes-
they are among the tools available to regenerative enchymal stem/stromal cells (MSC), which can
surgery nowadays. be found in several tissues.
In 2013, the International Federation for
Adipose Therapeutics and Science (IFATS) and
30.1.2 Principles and Techniques the International Society for Cellular Therapy
of Regenerative Surgery (ISCT) agreed on a definition that classified
ADSCs according to the following criteria [6]:
30.1.2.1 at Grafting, the Vascular-
F
Stromal Fraction, and ADSCs • Their capability of adhering to plastic and pro-
The adipose tissue has mesenchymal origins, and liferating in vitro
it is widespread throughout the whole organism, • Their capability of differentiating into adipo-
both on a superficial and visceral level. It was ini- cytes, chondrocytes, and osteoblasts
tially thought that the adipose tissue was a rela- • Immunophenotypical positivity for CD13,
tively inert tissue with the sole purpose of CD29, CD44, CD73, CD90, and CD105 and
providing thermic isolation, parenchymatous negativity for CD31 and CD45
organ support, and energy storage, but that was a
misconception. It later emerged that fat plays a With time, studies in vitro and on animal mod-
crucial role in regulating numerous endocrine els have progressively clarified that adipocytes
processes (such as the sensation of hunger, gain- and ADSCs are the populations most involved in
ing or losing weight, the peripheral sensibility to lipostructure.
30 Regenerative Surgery 467
Despite that, we are still far from fully com- • An outer area is closer to the vascularization
prehending their respective role in fat grafting and is about 300 μm thick, where both adipo-
and its mechanisms. cytes and ADSCs survive, which goes under
Engraftment percentages greatly vary between the name of surviving zone.
20 and 80%, according to the recipient area, its • An intermediate area between 600 and 1200 μm
perfusion, and its mechanical characteristics. thick, called the regenerative zone, where adi-
Such a high variability implies low chances of pocytes die, while ADSCs proliferate and dif-
predicting the final results and the almost ferentiate, thus replacing dead cells. Its
unavoidable need for several surgeries to obtain thickness varies according to the perfusion and
the desired results. the microenvironment of the recipient site.
The full process of engraftment has not been • An internal area that oxygen does not reach
thoroughly understood yet. Over the years, dif- hence making it impossible for both cell types
ferent theories have been proposed. The two to survive. Its thickness depends on the fat
main theories regarding fat engraftment are the graft diameter and the partial oxygen pressure
graft survival theory and the host replacement of the recipient site. The necrotic zone gets
theory [7]. generally replaced by scar tissue or, in vast
The graft survival theory was developed dur- areas, by oily cysts.
ing the 1950s by Peer and laid the foundations for
further understanding of fat grafting. According In normal perfusion conditions, the so-called
to this theory, adipocytes and cells transplanted critical radius has been evaluated to be about
into the recipient site are nourished by oxygen 16 mm long. Fat grafts with longer radii have
and nutrients, as long as a new vascularization showcased signs of necrosis. Reduced perfusion
coming from the recipient site reaches the graft and a consequently reduced partial oxygen pres-
and stabilizes it in the long term. sure determine a critical radius reduction and
Thus, purifying and injecting the highest thus signs of necrosis, even in smaller grafts [9].
amount of living cells, particularly adipocytes, These two theories are not mutually exclusive,
into the recipient site has been considered crucial and they present numerous similarities, first and
for many years. foremost, regarding the crucial role of vascular-
The host replacement theory, formulated by ization and neoangiogenesis in the recipient site.
Yoshimura in the early 2000s, takes its premise However, many of the factors regarding the
from the notion that, after 14 days, only a small engraftment process and the role that adipocytes
amount of the transplanted adipocytes was still and ADSCs play remain unknown.
vital. Adipocytes are exceptionally fragile
cells, and they have a low tolerance to hypoxic
damage. On the contrary, ADSCs have good
Key Points
resistance to the latter and can respond to isch-
ADSCs show features of the mesenchymal
emia/perfusion damages through increased
stem/stromal cells (MSCs), which can be
proliferation and by differentiating into adipo-
summarized as follows:
cytes and endothelial cells, thus triggering the
formation of new blood vessels. Furthermore, • The capability of adhering to plastic and
they secrete additional growth factors, able to proliferating in vitro
provoke neoangiogenesis, and recruit other • The capability of differentiating into adi-
precursor cells from the recipient site [8]. Their pocytes, chondrocytes, and osteoblasts
growing distance from the source of vascular- • Immunophenotypical positivity for
ization, as well as their different resistance to CD13, CD29, CD44, CD73, CD90, and
hypoxic damages, causes the formation of CD105 and negativity for CD31 and
three concentric areas within the fat graft CD45
(Fig. 30.2):
468 V. Cervelli and G. Storti
Fig. 30.2 The injected fat lobule could be divided into side to the inside, we have the surviving zone, the
three different zones, which are progressively more dis- regenerating zone, and the necrotic zone. ADSCs adipose-
tant from the recipient site’s vessels. Going from the out- derived stem/stromal cells
30 Regenerative Surgery 469
hips, trochanteric region, inner thigh, and knee The centrifugation, as described by Coleman,
area. Furthermore, we can distinguish between seems to obtain an optimal graft purification and
superficial and deep fat compartments. Although the removal of many components that could hin-
some authors have proposed the superiority of der the engraftment process, including broken
specific donor sites like the lower abdomen and adipocytes, fatty acids, red blood cells, and infil-
the inner tights, a general revision of the litera- tration fluid. Furthermore, it has been suggested
ture does not support this claim. Nonetheless, the that the centrifugation determines a higher final
quality of the evidence is low under this aspect. concentration of ADSCs in the purified graft.
The effect on the viability of ADSCs of local However, mechanical stress during centrifu-
anesthetics, part of the infiltration solution, has gation is detrimental to the fragile adipocytes that
also been debated. Even though some in vitro and could be disrupted in a higher number with this
preclinical evidence raised the problem of cyto- processing method.
toxicity of local anesthetics on ADSCs and there- The filtration, with or without washing, causes
fore postulated a consequently reduced graft less mechanical stress to the adipocytes than cen-
survival, these data have not been confirmed in trifugation, but more than decantation. It has a
clinical settings. While the use of local anesthet- discrete capacity of removal of the unwanted
ics is questioned, epinephrine is considered safe components and can concentrate quite efficiently
for cellular viability. ADSCs. Nonetheless, if performed with an open
The device and the technique used for fat aspira- system, filtration could expose the graft to the air
tion seem not to affect graft retention. Either for a relatively long time and impair its viability.
syringe aspiration, as initially described by Furthermore, it could be complicated to perform
Coleman, or vacuum-assisted liposuction or water- for large quantities of lipoaspirate. Closed sys-
assisted liposuction or ultrasound-assisted liposuc- tems are available, but they are disposable, and
tion has similar effect on the graft, without the costs are higher than for open ones.
significant benefits of one method over the others. The decantation applies minimal forces to the
Nonetheless, laser-assisted liposuction and the use harvested lipoaspirate and uses gravity force to
of a negative aspiration pressure below −760 mmHg separate the different components. This method
could significantly harm graft survival and adipo- preserves the adipocytic component while, on the
cyte viability, which is diminished by 90%. other hand, giving suboptimal results in terms of
It has been described that the use of larger graft purification. The decantation could be use-
cannulas for the harvesting process helps in pre- ful, especially when dealing with large amounts
serving a higher number of viable adipocytes. of lipoaspirate, but the excess of residual oil, cel-
Nonetheless, the clinical benefits related to this lular debris, and infiltration fluid could impair the
observation are not clear. engraftment.
The ideal processing protocol should purify the
graft at a maximum level, removing all the con-
Key Points
taminants and limiting cell dispersion and destruc-
The technique described by Coleman is the
tion. It should be a closed system to avoid external
first technique described that had reliable
contamination, and it should be quick and cheap
results in fat processing.
enough to be performed intraoperatively, thus
It is based on three main pillars:
allowing the immediate re-injection of the purified
graft without elongation of the operative time. • Syringe aspiration with a gentle nega-
Centrifugation, filtration with or without tive pressure
washing, decantation, and many other methods • Centrifugation for 3 min at 1200 g, dis-
have been tested to obtain the best results. carding the oily and the aqueous layers
Unfortunately, there are no data in support of one • Multiplanar infiltration of the purified
technique over the others to date. Each technique fat
described showed strengths and weaknesses.
470 V. Cervelli and G. Storti
Over the years, new classifications of the adi- treat specific areas of the body (Fig. 30.3). For
pose graft have emerged. The purified fat has example, macrofat in the face could be useful for
been classified into macrofat, microfat, and nano- cheek augmentation on a deep plane, while nano-
fat, according to the injected fat particles’ size. fat or microfat is more indicated for thinner areas
The macrofat and the microfat are harvested, like the eyelids, where small volumes and
respectively, with a 3 mm, two-hole cannula and extreme precision are needed.
with a 2 mm cannula with multiple holes, usually Optimal contact between the recipient site and
with sharp edges, ranging between 1000 mm and the graft is of capital importance to minimize the
600 mm of diameter. The different cannula sizes resorption and is the injection phase’s primary
determine a different size of the fat lobules goal.
among macro- and microfat. The following pro- Infiltrating fat with a small cannula in differ-
cessing method is variable, as described above. ent non-confluent tunnels, on multiple layers, and
The centrifuged microfat is shuffled 30 times in small quantities allows every fat graft to be
between two syringes connected by a Luer-Lock surrounded by vascularized tissue and increases
connector to obtain the nanofat. The emulsified survival chances.
fat obtained is then filtered with dedicated filters Moreover, graft perfusion by the recipient site
and results in a fluid product easier to inject even plays an important role. Hence, it is necessary to
with thin needles. The shuffling/filtration proto- assure the best possible contact between the fat
col, according to the inventors of the nanofat graft and the receiving area and minimize
technique, should rupture the adipocytes and mechanical stresses that may compromise
allow their removal together with cellular debris, vascularization.
thus increasing the concentration of ADSCs and Lastly, it has been speculated that either creat-
the regenerative properties of the nanonfat. ing a microenvironment that favors cellular pro-
Furthermore, the product obtained is extremely liferation and angiogenesis or the addition of
fluid and can also be injected in very thin areas cells capable of proliferating and differentiating
like the eyelids. into adipocytes and endothelial cells may increase
However, no strong evidence supports the fat engraftment and survival. These theories have
superiority of nanofat or microfat over the mac- laid foundations, respectively, for the addition of
rofat in terms of regenerative capacity. The main PRP to lipoaspirate, a process called platelet-rich
difference between these products is their fluidity lipotransfer (PRL), and the addition of SVF or
and, consequently, injectability, which could ADSCs, otherwise called cell-assisted lipotrans-
guide one product’s indication over the others to fer (CAL).
30 Regenerative Surgery 471
Lipoaspirate
%
50 purification
Cell Assisted
Lipoaspiration Mixing
Purification and Lipotransfer
50
% separation of the
SVF (mechanical
or enzymatic)
to inject the expanded cells. All these steps Table 30.1 Principal growth factors contained in
platelet-rich plasma and their functions
require extra costs and time and present numer-
ous regulatory obstacles. Thus, this approach is Growth
factors Biological functions
still far from a solution for daily clinical use.
VEGF Regulation of collagen secretion
Some meta-analysis showed that CAL pres- Stimulates migration and proliferation of
ents better engraftment and volume retention vascular endothelial cells
after time, especially in some areas like the face, Promotes the formation of new vessels
while there is no significant advantage in the EGF Potent mitogen
Increases the expression of genes
breast area. Despite that, evidence in favor of this responsible for DNA synthesis and cell
technique is not clear enough to draw any definite proliferation
conclusion [14]. Regulation of the mitogenesis in
mesenchymal stem cells and epithelial cells
Promotion of angiogenesis and chemotaxis
Key Points of endothelial cells
The SVF is embedded into the perivascular Regulation of collagenase secretion
b-FGF Multifunctional protein with regulatory,
extracellular matrix and is constituted of morphologic, and mitogenic effect
different cellular types like pericytes, endo- Regulation of endothelial cells, fibroblastic
thelial cells, mononuclear cells, lympho- cells, and ADSCs
cytes, and ADSCs. ADSCs are about 20% Stimulation of angiogenesis and the
formation of new blood vessels from the
of the cellular component of the SVF. preexisting vasculature
It is necessary to separate the SVF from PDGF First responsible for connective tissue
the ECM and collect it to enrich the fat healing
grafting with the SVF. This separation can Important regulator of the mitogenesis in
ADSCs
be done with mechanical methods or enzy-
Regulation of the chemotaxis of ADSCs
matic methods. In the EU, only mechanical Regulation of the collagen synthesis and
methods are allowed intraoperatively with- secretion
out the use of GMP facilities. Nonetheless, TGF-® Both autocrine and paracrine activity
mechanical methods have more cell disper- Stimulation of the proliferation of the
ADSCs
sion and a lower cell yield. Regulation of the collagen synthesis
It has not been clearly demonstrated that Regulation of the endothelial mitogenesis
an enrichment of the graft with SVF like in Immunomodulation of macrophages and
the CAL determines a better outcome in lymphocytes
terms of graft survival. ADSCs adipose-derived stem/stromal cells
• Dose of platelets, i.e., the absolute platelet Over the years, different strategies have
number within the PRP volume been employed to overcome these possible
• Efficiency of the platelet-concentration stressors on the graft. The strategies
method, that is, the increase, measured in per- employed can be grouped into three main
centage, of platelet volume per plasma categories:
volume • Improvements in the surgical technique
• Purity of the final product resulting from the that include an increase in the vital cells
contamination with leucocytes and red blood available, a reduction of the cellular
cells loss, and an optimal purification of the
• Activation (or lack thereof) through exoge- graft
nous coagulation factors • Enrichment of the graft either with cel-
lular products like SVF or ADSCs or
Thanks to the growth factors it contains, PRP with factors enhancing proliferation and
prompts the microenvironment toward a pro- differentiation like the PRP
regenerative transition and increased cell prolif- • Pre-conditioning and preparation of the
eration and neoangiogenesis [17]. Furthermore, recipient site with techniques like the
PRP has been proved to increase ADSCs prolif- external expansion or the reverse expan-
eration and engraftment, with an optimum dose sion and use of scaffolds
of 0.5 mL of PRP every mL of lipoaspirate,
whenever mixed with purified lipoaspirate. Fat
grafts that get mixed with PRP are called platelet-
rich lipotransfer (PRL). 30.1.2.4 Scaffolds and Tissue
However, even if PRP, injected on its own, Engineering
may apparently hold advantages in terms of Every tissue showcases not only the cellular
microenvironment conditioning, as it is the case component but also an extremely specialized
for lower limb ulcer, for example, it is hard to supporting structure, consisting of ECM. This
draw any definite conclusion to date when it structure is particularly relevant for spatial and
comes to adipose tissue survival. three-dimensional tissue organization and the
It is mostly unclear whether there may be an physical and mechanical properties of said
efficient minimum dose, both regarding the tissues.
absolute platelet number and the platelet concen- In regenerative surgery, tissue engineering
tration capacity. There are also still doubts aims to artificially recreate the specific properties
regarding the eventual benefits offered by PRP every human tissue possesses to fulfill its
activation in terms of efficacy. Finally, compar- function.
ing and classifying all the studies to obtain good- In order to create a result as similar as possible
quality, clinical scientific evidence is challenging, to the model tissue, this branch uses several com-
considering the heterogeneity of the applied posite components.
preparation methods and, consequently, their There usually is a cellular component (e.g.,
resulting PRP [18]. ADSCs); proliferative and differentiating fac-
474 V. Cervelli and G. Storti
a b c
Fig. 30.5 Face rejuvenation using fat transfer. In (a), we We can notice a general improvement in the skin texture
can see the patient preoperatively, while in (b), we can see and improved fullness of the zygomatic area and the naso-
the different types of fat graft used (macrofat in red, labial folds. Furthermore, the rejuvenation of the tear
microfat in green, and nanofat in blue) and the areas of trough area with reduced visibility of the nasojugal groove
injection. We can see the patient at 1-year post-op in (c). is noticeable
loss but also ptosis of the natural fat compart- 30.1.3.4 Regulatory Issues
ments. The traditional surgery relocates the ptotic For the European regulation authority, fat graft-
fat compartments in their anatomical position, ing is feasible for autologous use in the intraop-
while the fat graft replaces the lost volume. erative setting. Centrifugation, filtration,
Furthermore, liposuction for fat harvesting could decantation, and mechanical methods of separa-
be directly performed on the face, thus helping tion of the SVF are considered minimal manipu-
contour redefinition and enhancement. lation, and therefore they do not require the use
As mentioned above, the use of different types of Good Manufacturing Practice (GMP) facili-
of fat graft (macrofat, microfat, and nanofat) ties. Furthermore, purified fat or the SVF should
allows correcting precisely each area of the face, be used for homologous use, i.e., following a
even the thinnest ones like the tear-trough area, like-for-like principle. Therefore, every use of
thus avoiding overgrafting, which could be detri- these cells, either in areas where they are not
mental on the face. physiologically present or in processes in which
The use of fat transfer and PRP in face surgery they do not physiologically take part, has to be
has also been tested in reconstructive settings, considered only in a controlled setting after the
with good results. In particular, it helps in replac- approval of an ethical committee.
ing the volumes lost in the Parry-Romberg syn- Processes like SVF separation with collage-
drome and correcting the consequent deformity. nase, ADSC isolation and expansion, and tissue
For similar reasons, fat grafting has also been engineering are considered, according to the
used on the face to treat the cutaneous European legislation, as major manipulations and
manifestation of scleroderma because it improves require a GMP laboratory to be performed.
skin quality, its elasticity, reduces the scarring, While the regulation about cellular products is
and corrects contour deformities, recreating uniform in the whole EU, legislation about PRP
fullness. differs in each country.
478 V. Cervelli and G. Storti
Take-Home Messages
• Regenerative surgery is a crucial ele- References
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Advanced Reconstructive Plastic
Surgery
31
Dicle Aksoyler and Hung-Chi Chen
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 481
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_31
482 D. Aksoyler and H.-C. Chen
and Buncke harvested free omental flap for cra- using laparoscope, combined chimeric flaps, and
nial defect [5]. In 1973, Daniel and Taylor per- composite tissue allografts are also part of
formed the first free fasciocutaneous groin flap advanced microsurgery.
[6]. In the 1970s and 1980s, Mathes and Nahai
introduced the concept of muscle and musculo-
cutaneous flaps. The well-described reconstruc- 31.2 Perforator Flaps
tion options from the head and neck, trunk, and
upper and lower extremity illustrated complete Advances on the field of reconstructive surgery
algorithm for whole body reconstruction [7]. In such as newly developed imagining techniques to
1981, Ponten reintroduced another option for demonstrate pedicle-perforator-tissue associa-
securing a large cutaneous flap that totally tion, cadaver researches to show detailed flap
omitted a muscle [8]. Afterward, Cormack and anatomy or its possible variations, and delicate
Lamberty defined the basic classification for microsurgical instruments and concerns for more
fasciocutaneous flaps [9]. In 1987, Taylor and aesthetic appearance in both the recipient and
Palmer shared the concept of “angiosome” or donor sites developed the next frontier in the field
“vascular territory” and also choke vessels [10]. of microsurgery which was “perforator flaps—a
These descriptions opened the era of perforator balance between form and function.” The princi-
flaps. Approximately 400 cutaneous perforators ple of performing perforator flaps is based on the
have been described so far. After the descrip- measurement of the particular tissues required
tion of perforator flaps based on major vessels, for reconstruction and, in retrograde manner, dis-
Wei and Mardini described the freestyle perfo- section from perforator to main pedicle to pro-
rator flaps. According to their proposal, any vide arc of rotation for use as a pedicled flap or
region of the body with an audible, pulsatile transferring it as a free flap (Table 31.1).
Doppler signal can be chosen as a donor site.
The flap can be designed and raised in any
region of the body that meets the unique 31.2.1 Breast Reconstruction
requirements of skin color, thickness, texture,
and donor site morbidity [11]. Masia et al. pro- The development of perforator flaps was initiated
posed to plan and design a DIEP flap based on with autologous breast reconstruction. Autologous
the distribution of perforators on the multide- breast reconstruction has undergone continuous
tector row computed tomography and subse- development beginning with transverse rectus
quently with non-contrast magnetic resonance abdominis (TRAM) flap in 1979 [15]. After that,
imaging [12, 13]. techniques were developed to carefully dissect the
Recently, Novadaq SPY imaging (Novadaq perforating vessels in a retrograde manner through
Technologies, Inc., Bonita Springs, Florida), a the muscle to preserve function of abdominal
fluorescent angiography system that presents musculature. Deep inferior epigastric artery per-
basic and efficient intraoperative real-time sur- forator flap (DIEP) was based on the concept of
face angiographic imaging, has augmented our providing natural tissue breast reconstruction
understanding of the physiology of these flaps. with the implied protection of the abdominal wall
This technology is helpful for evaluating vascular from surgical damage. Initially, DIEP flap was
anastomosis and flap perfusion intraoperatively described for head and neck reconstruction.
and facilitates surgical decision-making [14]. All Afterward, it was popularized for breast recon-
of these developments encouraged surgeons to struction, and since that time, DIEP has been pref-
seek other types of reconstructions to present bet- fered as the most common approach for breast
ter results both in form and in function and repair reconstruction [16]. Yet, in the circumstances of
the defect with similar type of tissue. insufficient abdominal tissue for DIEP flap due to
Supermicrosurgery, voice reconstruction, lymph- low body mass index, poor perforators for DIEP
edema surgeries, harvesting of intestinal flap or previously used DIEP alternative reconstruc-
31 Advanced Reconstructive Plastic Surgery 483
tion options were sought in the field of microsur- breast defects. To cover the excised area, lateral
gery [17].For instance; Profunda Artery Perforator intercostal artery perforator flap or thoracodorsal
flap (PAP) due to its hidden scar in donor site or artery perforator flaps have been used as applica-
providing bilateral symmetric breasts [17], ble choices [20, 21].
Transverse Upper Gracilis flap (TUG) due to its
hidden scar in donor site [16], Combined PAP-
Key Point
TUG flap; for harvesting bulky tissue especially if
Unlike other reconstructive procedures,
the contralateral breast is already C or D cup [18],
cosmetic results are important for patients
Superior Gluteal Artery Perforator flap (SGAP) or
with breast cancer treatment due to close
Inferior Gluteal Artery Perforator flap (IGAP);
association between femininity.
due to their adequate pedicle length (5–10 cm)
and large volume of fat, easily hidden scar under
the short pants [19], Superficial Inferior Epigastric
Artery Flap (SIEA); especially in the circum- 31.2.2 Head and Neck
stance of poor DIEP perforators have been con- Reconstruction
sidering d ifferent options for breast reconstruction
[16]. Instead of total mastectomies, breast-con- Thoracodorsal artery perforator flap offers wider
serving surgeries have been performed with addi- arc of rotation for locoregional coverage of the
tional chemoradiotherapy. After this type of defects of the upper extremity, shoulder, neck,
surgery, patients usually have lateral site of partial axilla, and chest [22].
484 D. Aksoyler and H.-C. Chen
The anterolateral thigh flap is a workhorse flap Following burns, facial scarring, contractures,
in reconstructive surgery as a pedicled or free flap congenital nevi, vascular tumors in children, and
to cover wounds all over the body [22]. scalp defects, pre-expanded perforator flaps can
Posterolateral thigh flap is an alternative free flap be designed as a pedicled or free flap [22].
for ALT flap to cover head and neck defects.
Tips and Tricks
Pedicle propeller design perforator flaps
31.2.3 Perineum Reconstruction
overcome the main obstacle of length-to-
width ratio on the restriction of local flaps.
As a result of trauma, decubitus ulcer, or spine
Their applicability have been expanded to
surgery, which can cause lumbal defects, these
reconstructions of the head and neck, upper
defects can be reconstructed with lumbar artery
extremity, lower extremity, trunk, and
perforator flaps [22].
perineum [22, 24].
Profunda artery perforator flap is a reliable
option for regional coverage of pressure sores
and vulva and perineal reconstruction and also
can be considered as a free flap for coverage of 31.2.6 Freestyle Perforator Flaps
the lower extremity or breast reconstruction
[22]. Moreover, it can be combined with trans- Recently, a new concept, “freestyle perforator
verse upper gracilis flap (PAP-TUG) for obliter- flaps,” has been well recognized and successfully
ating the fistulas of perineal defects as pedicled performed especially for patients with diabetes
design [18]. and previously irradiated or traumatized extremi-
Superficial femoral artery perforator flap not ties where it is hard to find a reliable recipient ves-
only offers robust blood supply but also pro- sel as a source of pedicle with proper flow.
vides wide locoregional tissue for coverage of Freestyle flaps can be harvested as pedicled or free
wide leg defect related to soft tissue tumors or flaps and can be composed of different tissue
traumas [22]. types. Once a perforator is identified, it can be dis-
sected from distal to proximal to exclude any ana-
tomical inconsistency. Identifying the perforators
31.2.4 Lower Extremity are essential, and they can be easily detected by a
Reconstruction simple handheld Doppler ultrasound probe.
a c
Fig. 31.1 (a) Patient was referred by dermatologist due of lateral malleolus and midpopliteal fossa. Usually perfo-
to suspicious premalign hyperpigmente lesion on the pre- rators start proximally 6–8 cm below this line from the
tibial reion. Previous pathology report had excluded the superior edge. (c) MSAP flap was harvested based on two
malignant melanoma and squamous cell carcinoma. (b) perforators. (d) Rotation of flap can be seen. (e) Closure
Perforators was founded the line between posterior edge of the wound
31.2.8 C
ombined Flaps (Conjoined
Key Points Flaps, Composite Flaps,
Nowadays, this concept has been rede- Chimeric Flaps)
fined as the perforator-to-perforator anas-
tomosis. If the pedicle of the flap is short Despite the general applications of workhorse
or recipient vessels lie too deep to perform flaps in reconstructive microsurgery, the research
anastomosis, then supermicrosurgical continues for alternative, reliable, and safe donor
techniques can be applied to overcome sites with consistent anatomy and low morbidity
these obstacles. When the perforator or an to offer three-dimensional reconstruction. The
end vessel has a strong pulse, it can be major advantages of combined flaps are several.
checked with intraoperative handheld First, their reliable dual blood supply provides
Doppler or with the use of a microscope watershed areas at the edge of each angiosome.
and can be used as a recipient vessel. This robust perfusion from one flap to other one
Preoperatively computed tomography is contributed by choke vessels. Second, their
angiography (CTA) can be obtained for proposed multistructural tissue reconstruction is
perforator mapping [18]. achieved in one stage [18].
a b c
Fig. 31.2 (a) SCIP flap (superficial circumflex iliac per- for coverage of right palm, fingers, and thenar web. The
forator flap) can provide a very thin coverage for the hand, picture showed that the fingers could extend fully. (b) The
fingers, and other places such as around the ankle which fingers could flex fully with the thin flap. (c) This was the
need thin flap for reconstruction. This was the SCIP flap dorsal view of the right hand
31 Advanced Reconstructive Plastic Surgery 487
a b c
d e f
Fig. 31.3 (a) Patient had been treated by free fibula flap chimeric flap was harvested. The rib was attached to the
for buccal cancer. Following radiotheraphy, patient had serratus anterior muscle and split of muscle harvested due
osteoradionecrosis, shrinkage on the flap skin, and drool- to avoid of winging scapula. (e) Flap was on the table.
ing. (b) After excision of the necrotic bone and release of TDAP perforator and serratus branch accompanied to tho-
contraction deltoid branch of thoracoacromial artery and racodorsal artery and vein. (f) Inset of flap. Neck contrac-
vein were prepared for anastomoses. (c) Drawing and sur- ture was also broken with extra soft tissue
gical plan of TDAP-serratus flap with eighth rib. (d) The
a b
c d
Fig. 31.4 (a) 38-year-old woman in an outpatient clinic edge of jejunum flap was planned to inset gingivobuccal
due to choking and decreased oral intake ability following sulcus, and distal end of flap was planned to left neck tem-
caustic injury. Diversionary loop with free jejunum flap porarily for observation. (d) After the inset, two nasogas-
was planned. External jugular vein (EJV) and TCA (trans- tric tubes were inserted into jejunal lumen temporarily to
verse cervical artery) were prepared as recipient vessels. keep passage open, deltopectoral flap was harvested for
(b) External jugular vein (EJV) and TCA (transverse cer- covering both flap and anastomoses, and split-thickness
vical artery) were dissected off meticulously. (c) Superior skin graft covered the donor site
a b c
d e f
Fig. 31.6 (a) Patient had been suffering grade 3 lymph- vein in an end-to-end manner. Lymphaticovenular anasto-
edema following treatment of cervical carcinoma. mosis which is performed to improve the lymphatic flow
Recurrent cellulitis, leg discrepancy, difficulty of walking, from lymphatic system to the venous system. It is indi-
and aesthetic concerns were the main complaints. (b) cated for mild cases of lymphedema in the extremity. (e)
Right gastroepiploic artery-based lymph node flap (omen- The gastro-omental flap divided in two pieces. 40% of the
tum) was harvested endoscopically by the general sur- flap was placed in the ankle. Medial plantar artery and
geons. It was stored in ice for 3–4 h to get sufficient time vein were used for anastomoses. 60% of the flap was
for lymphaticovenular anastomoses. (c) After the Patent attached to the popliteal region. The medial sural artery
blue injection the blue dyed lymphatic vessel anasto- and vein were used for anastomoses. (f) The inset of flap
mosed to superficial vein in side-to-end manner. (d) in the ankle region. Some parts of flap were covered with
Another blue dyed lymphatic anastomosed to superficial split-thickness skin graft
22. Mohan AT, Sur YJ, Zhu L, Morsy M, Wu PS, Moran 37. Onishi K, Maruyama Y, Yataka M. Endoscopic har-
SL, et al. The concepts of propeller, perforator, vest of the tensor fasciae latae muscle flap. Br J Plast
keystone, and other local flaps and their role in the Surg. 1997;50(1):58–60.
evolution of reconstruction. Plast Reconstr Surg. 38. Seify H, Jones G, Sigurdson L, Sherif A, Refky M,
2016;138(4):710e–29e. Bolitho G, et al. Endoscopic harvest of four muscle
23. Patel NG, Ratanshi I, Buchel EW. The best of flaps: safe and effective techniques. Ann Plast Surg.
abdominal wall reconstruction. Plast Reconstr Surg. 2002;48(2):173–9.
2018;141(1):113e–36e. 39. Bass LS, Karp NS, Benacquista T, Kasabian
24. Ramesha KT, Vijay J, Shankarappa M. Propeller flaps AK. Endoscopic harvest of the rectus abdominis free
and its outcomes—a prospective study of 15 cases flap: balloon dissection in the fascial plane. Ann Plast
over two-years. J Clin Diagn Res. 2014;8(1):87–9. Surg. 1995;34(3):274–9; discussion 9–80.
25. Hong JP. The use of supermicrosurgery in lower 40. Onishi K, Maruyama Y. Cutaneous and fascial vascu-
extremity reconstruction: the next step in evolution. lature around the rectus abdominis muscle: anatomic
Plast Reconstr Surg. 2009;123(1):230–5. basis of abdominal fasciocutaneous flaps. J Reconstr
26. Cigna E, Chen HC, Ozkan O, Sorvillo V, Maruccia Microsurg. 1986;2(4):247–53.
M, Ribuffo D. The anteromedial thigh free flap anat- 41. Gherardini G, Gurlek A, Staley CA, Ross DA,
omy: a clinical, anatomical, and cadaveric study. Plast Pazmino BP, Miller MJ. Laparoscopic harvesting of
Reconstr Surg. 2014;133(2):420–9. jejunal free flaps for esophageal reconstruction. Plast
27. Hallock GG. Color duplex imaging for identifying per- Reconstr Surg. 1998;102(2):473–7.
forators prior to pretransfer expansion of fasciocuta- 42. Liguori G, Trombetta C, Bucci S, Salame L, Bortul M,
neous free flaps. Ann Plast Surg. 1994;32(6):595–601. Siracusano S, et al. Laparoscopic mobilization of neo-
28. Masia J, Olivares L, Koshima I, Teo TC, Suominen S, vagina to assist secondary ileal vaginoplasty in male-
Van Landuyt K, et al. Barcelona consensus on super- to-female transsexuals. Urology. 2005;66(2):293–8;
microsurgery. J Reconstr Microsurg. 2014;30(1):53–8. discussion 8.
29. Koshima I, Yamamoto T, Narushima M, Mihara M, 43. Ozkan O, Akar ME, Ozkan O, Mesci A, Colak
Iida T. Perforator flaps and supermicrosurgery. Clin T. Microvascular augmented pedicled jejunum trans-
Plast Surg. 2010;37(4):683–9, vii–iii. fer for vaginal reconstruction using a laparoscopy-
30. Hallock GG. Further clarification of the nomen- assisted technique. Microsurgery. 2008;28(8):671–5.
clature for compound flaps. Plast Reconstr Surg. 44. El-Muttardi N, Jabir S, Win TS. Pearls and pitfalls
2006;117(7):151e–60e. of laparoscopic harvest of omental flap for sternal
31. Nicoli F, Orfaniotis G, Lazzeri D, Lim SY, wound reconstruction in patients with significant
Kiranantawat K, Chen PY, et al. The latissimus dorsi- cardiac dysfunction. J Plast Reconstr Aesthet Surg.
groin-lymph node compound flap: a comprehensive 2013;66(12):e394–5.
technique with three features including skin coverage, 45. Scott JC, Jones B, Eisele DW, Ravich WJ. Caustic
restoration of motor function, and prevention of upper ingestion injuries of the upper aerodigestive tract.
limb lymphedema. Microsurgery. 2016;36(8):689–94. Laryngoscope. 1992;102(1):1–8.
32. Boonipat T, Ji L, Manrique OJ, Chen HC. Combined 46. Ku PK, Vlantis AC, Leung SF, Lee KY, Cheung DM,
bipedicled latissimus dorsi and groin flap for ante- Abdullah VJ, et al. Laryngopharyngeal sensory defi-
rior chest wall reconstruction. BMJ Case Rep. cits and impaired pharyngeal motor function predict
2019;12(5):e227372. aspiration in patients irradiated for nasopharyngeal
33. Trignano E, Fallico N, Nitto A, Chen HC. The treat- carcinoma. Laryngoscope. 2010;120(2):223–8.
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a combined latissimus dorsi and serratus anterior and years of single surgeon experience in the reconstruc-
rib free flap. Microsurgery. 2013;33(3):173–83. tion of esophagus and voice with free ileocolon flap
34. Petrovic I, Panchal H, De Souza Franca PD, following total pharyngolaryngectomy. J Surg Oncol.
Hernandez M, McCarthy CC, Shah JP. A systematic 2018;117(3):459–68.
review of validated tools assessing functional and aes- 48. Chen SH, Yeh LF, Ciudad P, Chen HC. Successful
thetic outcomes following fibula free flap reconstruc- surgical treatment of intractable chylous ascites using
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36. Elia R, Di Taranto G, Amorosi V, Ngamcherd S, 50. Brown EN, Dorafshar AH, Bojovic B, Christy MR,
Alamouti R, Liao LY, et al. The versatility of the tho- Borsuk DE, Kelley TN, et al. Total face, double jaw,
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Transplant and Plastic Surgery
32
Marissa Suchyta, Krishna Vyas, Waleed Gibreel,
Hatem Amer, and Samir Mardini
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 495
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_32
496 M. Suchyta et al.
injuries. Advances in reconstructive microsur- first successful hind limb transplant in pigs with
gery and transplantation immunology have per- an updated immunosuppressive therapy of cyclo-
mitted many successful transplants, including sporin, mycophenolate mofetil, and prednisone
abdominal wall, hands, face, larynx, peripheral [10]. Furthermore, the introduction of FK 506
nerves, and vascularized tendons. However, dif- (tacrolimus) in solid-organ transplant in the
ferent tissues in VCAs have varying antigenici- 1990s led to a more potent immunosuppressive
ties, and the risks of obligatory lifelong regimen [11]. These more potent immunosup-
immunosuppression remain a major challenge. In pressants allowed for the first successful hand
addition to the complications of immunosuppres- transplant to be performed in 1998 by Jean-
sion such as increased incidence of opportunistic Michel Dubernard in France [12].
infection, malignancy, and end-organ toxicity,
chronic rejection often negates favorable long-
term results. Key Point
The pathway to successful VCA has relied The success of VCA has immensely relied
upon advances in both microsurgical reconstruc- upon advances in immunosuppression pro-
tion and immunosuppression. Jacobson and tocols, leading to current protocols that
Suarez published the first successful microsurgi- have enabled composite allotransplantation
cal vessel anastomosis in 1960, leading to the with long-term success.
ability to perform complex free-flap surgeries,
ultimately used also in VCA [4]. In parallel,
advances in solid-organ transplantation estab- Since the first hand transplant, the field of
lished the foundation for the immunosuppression VCA has evolved immensely. The first partial
necessary in VCA. Joseph Murray’s first kidney face transplant was performed in 2005, also in
transplant between identical twins in 1954 dem- France, leading to new possibilities for patients
onstrated the surgical feasibility of solid-organ with complex facial deformities [13]. The field of
transplant [5]. The late 1950s saw the publication VCA has further evolved and now encapsulates a
of seminal papers in immunology, which demon- variety of transplants, including penile, uterus,
strated the potential to induce functional toler- abdominal wall, and laryngeal transplants, all
ance of solid organs through chemical described in this chapter [2].
immunosuppression [6, 7]. This research ulti- Although VCA has many similarities to solid-
mately led to the introduction of clinically used organ transplantation, the challenges that VCA
immunosuppression, such as azathioprine in faces are unique. VCAs may be crucial to social
1961. The early 1980s saw a significant improve- integration and improve the ability of self-care,
ment in immunosuppressant medication with the but they are not life-saving and thus shift the risk-
introduction of the first calcineurin inhibitor— benefit calculations for lifelong immunosuppres-
cyclosporin [8]. These advances were crucial to sion and its accompanying complications.
the implementation of VCA. Furthermore, the success of VCA is contingent
The importance of advancing immunosup- on functional outcomes, which, in most cases, is
pression protocols was demonstrated by the first dependent on successful nerve regeneration.
published hand transplant performed in Ecuador
by Robert Gilbert in 1964 [9]. The patient was
placed on the limited immunosuppression avail- 32.2 Hand Transplant
able at that time consisting of corticosteroids,
azathioprine (Imuran), and a single dose of radia- Humans postulated about limb transplantation as
tion. This transplant was rejected within 2 weeks far back as the fourth century [1]. The first hand
from transplant. It did, however, demonstrate that transplant, however, was performed in Lyon,
the technical aspects of the procedure could be France, in 1998 and the second in 1999 in
performed. Subsequent animal studies led to the Louisville, Kentucky, USA [12, 14]. Since these
32 Transplant and Plastic Surgery 497
initial hand transplants, over 120 additional (DASH) scores of 72 published hand transplants
transplants have been performed. Transplants at 1 year post-transplant were an average of 38,
have occurred in geographically desperate loca- and at 10 years post-transplant an average of 16,
tions covering North America, Latin America, demonstrating quantitative functional improve-
Europe, Asia, and Australia. ment [17, 18]. Most patients reported enough
The technical aspects of hand transplant motor function to perform acts of daily living
greatly mirror that of hand replantation surgery. (Fig. 32.1).
However, there are notable differences. First, in
hand replantation, tissue availability is largely
outside the surgeon’s control. This includes the 32.3 Face Transplant
availability of soft tissue, which is often missing
from the initial injury. Furthermore, in hand Face transplantation is an innovative procedure
replantation, forearm length is sometimes short- for patients with facial deformities who have
ened to account for the loss of missing bone and exhausted traditional reconstructive options.
to allow primary vascular anastomosis (without Over 40 facial transplants have been performed
the need for vein grafts), primary nerve repair worldwide for defects from a variety of etiolo-
(without the need for nerve grafts), and primary gies, including ballistic injuries, animal attacks,
tendons repair (without the need for tendon severe burns, and advanced neurofibromatosis
grafts). In contrast, in VCA, there is greater type 1 [19].
control over final arm length, since the donor and Transplants have included both soft tissue and
recipient forearm osteotomies can be carefully underlying bones, including the maxilla and
planned and precisely executed to match original mandible [9, 13] (Fig. 32.2). Motor function is
length. Finally, flexor and extensor tendon ten- restored by performing a neurorrhaphy between
sion can be reestablished to optimize functional the donor and recipient’s facial nerve, either dis-
outcomes [15]. tally at the level of the facial nerve branches (to
The surgical procedure involves bony fixation, prevent potential synkinesis from aberrant regen-
vessel anastomosis (of the radial or ulnar artery eration) or proximally at the level of the facial
and one or two veins), nerve coaptation (median, nerve trunk. Depending on the type of the trans-
ulnar, and radial, as well as some more distal plantation, coaptation of the infraorbital and infe-
branches depending on the level of injuries rior alveolar nerves is performed to aid in sensory
including the palmar cutaneous branch of the restoration. The difference in synkinesis between
median nerve and the dorsal ulnar sensory nerve), proximal and distal coaptation has not been thor-
and reapproximation and repair of flexor and oughly evaluated. Our group prefers distal facial
extensor tendons. nerve coaptation to minimize the theoretical
chance of aberrant reinnervation, and, hence,
minimize the chance of synkinesis, and to hasten
Key Point functional recovery given the short distance the
In many respects, the technical aspects of nerve fibers need to regenerate to reach the target
hand transplantation surgery mirror those muscles.
of hand replantation. However, there is
greater control over final arm length since
the donor and recipient forearm osteoto-
Key Point
mies can be planned.
Distal nerve coaptation in face transplant,
minimizing the length of regeneration nec-
essary into donor tissue, may quicken func-
Over 75% of patients have reported improved tional recovery as well as minimize
quality of life following hand transplantation synkinesis.
[16]. Disabilities of the arm, shoulder, and hand
498 M. Suchyta et al.
a b
c d
Fig. 32.1 The recipient of the first US hand transplant (Kvernmo, H. D., Gorantla, V. S., Gonzalez, R. N., &
demonstrates functional results 5 years post-surgery: (a) Breidenbach III, W. C. (2005). Hand transplantation: A
extension, (b) flexion, (c) supination, and (d) pronation future clinical option? Acta Orthopaedica, 76(1), 14–27)
Fig. 32.2 In the case performed at Mayo Clinic, the making in planning osteotomies and an ideal reconstruc-
recipient’s extensive defect is demonstrated in the middle. tion (©SamirMardini 2021. All Rights Reserved)
Virtual surgical planning enabled preoperative decision-
Vessel anastomosis choice in face transplant is blood supply to the maxilla, this is also an option.
also largely dependent upon the tissues trans- To include the entire scalp, the posterior occipital
planted and the defect to be reconstructed [20]. should also be included. Although outcomes in
For most parts of the face, the facial vessels can face transplant are not standardized, systematic
be used. Venous outflow can be established via reviews have demonstrated that facial transplan-
the common facial vein. The facial vein is often tation leads to an improved quality of life and
sufficient to drain the face. If it is feasible to functional outcomes in almost all reported cases
include the internal maxillary to provide better [21]. For example, sensory improvement occurred
32 Transplant and Plastic Surgery 499
Ext pudendal a.
Defect
Ext pudendal a.
Buck’s fascia
Cavernosal a.
Cavernosal a.
Dorsal artery
Dorsal artery
Cavernosal a.
Dorsal artery
© JHU 2013
Fig. 32.3 The vascular anatomy and anastomoses per- (2014). Technical Approach to Penile Transplantation.
formed in penile transplant (Tuffaha, S., Sacks, J., Shores, Vascularized Composite Allotransplantation, 1(1, 2),
J., Brandacher, G., Lee, W. A., Cooney, D., & Redett, R. 69–70)
between 3 and 8 weeks post-transplant [22]. first reported case, the urethral mucosa of donor
Improvement in breathing, speaking, and facial and recipient was re-approximated, as was the
movement was enhanced in 93, 71, and 76% of corpora spongiosum and the tunica albuginea
published cases, respectively. Motor recovery [24]. Anastomoses included the superficial and
occurred for most patients between 6 and deep dorsal veins and the dorsal penile artery and
18 months. Despite the need for more standard- nerve. The first successful long-term penile trans-
ized outcomes measurements, it is clear that plant was performed in South Africa in 2014 due
facial transplantation has restored many of the to complications from a circumcision. Due to
recipients’ abilities to integrate into society as fibrosis of the dorsal penile artery, the inferior
well as led to immense functional improvement, epigastric and superficial external pudendal arter-
including decannulation and removal of feeding ies were used [25]. To date, two other penile
tubes in most cases in which they were initially transplants have been performed successfully
present. (Fig. 32.3).
Penile transplants provide the opportunity to Uterine transplantation is a surgical option for
restore urogenital function. The first penile trans- women who present with absolute uterine factor
plant was performed in 2006 in Guangzhou infertility due to congenital Müllerian anomalies
General Hospital in China [23]. This transplant such as uterine agenesis or malformation, a surgi-
was successful surgically, but the patient cally removed uterus or another acquired condi-
requested it removed 14 days following surgery tion of the uterus (such as intrauterine adhesions)
due to psychological concerns. This emphasizes leading to implantation failure [26].
the need for extensive presurgical recipient In uterus transplantation, the vascular pedicle
screening and counselling in VCA. of the internal iliac artery and vein of the donor
Penile transplant requires collaboration with a are anastomosed with the external iliac artery and
urologist to restore urogenital integrity. In the vein of the recipient [27]. Alternatively, the great
500 M. Suchyta et al.
saphenous vein has been utilized as a graft to of 16 (37.5%) pregnancies faced major complica-
anastomose the short ends of the uterine vessels tions during gestation, and preterm births
of the transplant to the recipient’s external iliac occurred in 10/16 (62.5%).
vessels. The donor and recipient vaginas are then Unlike the other transplants described, a
anastomosed. In cases of congenital uterine agen- uterus transplant is designed to be temporary and
esis, the creation of a neovaginal vault prior to removed by hysterectomy following the desired
surgery is necessary. number of births. Also in contrast to other VCA
The first live birth following uterus transplan- surgeries described in this chapter, 80% of
tation occurred in 2014 in Sweden reported by reported transplants have utilized a living donor
Brännström [28]. More than 60 uterine trans- [29]. This leads to even more necessary screening
plants have been performed, with 18 live births and ethical concerns, as discussed later in this
currently reported [29]. The majority of these chapter.
cases reported return of menstruation within the
first 3 months after surgery. All infants born fol-
lowing uterine transplants had normal Apgar 32.6 Abdominal Wall Transplant
scores at 10 min. A systematic review (22 studies
and 3 press releases) of safety and efficacy out- Abdominal wall transplant is a procedure that is
comes of uterus transplantation and IVF for con- an alternative option to primary wall closure in
genital or acquired uterine factor infertility in the patients undergoing intestinal and multivisceral
first 52 recipients showed that 38/52 (73.1%) of organ transplants [31] (Fig. 32.4). In 20% of
surgical procedures led to the restoration of uter- intestinal transplant patients, primary closure of
ine function in recipients, 12/52 (23.1%) of the abdominal wall is not technically feasible;
recipients experienced postoperative complica- VCA provides an opportunity to perform simul-
tions requiring hysterectomy, and 2/52 (3.8%) of taneous abdominal wall transplantation from the
procedures failed due to intraoperative complica- same donor with no additional risk of
tions [30]. About 40% (16/38) of patients immunosuppression.
achieved a pregnancy, including two women who Abdominal wall transplant vessel anastomosis
gave birth twice. In this systematic review, uter- can be performed using the iliac vessels of the
ine transplantation-IVF pregnancies led to 16 donor to the recipient’s iliac or femoral arteries
deliveries, and all newborns were healthy. Six out [32]. Therefore, a microscopic approach must
Fig. 32.4 66-year-old male recipient of an abdominal (Honeyman, C., Dolan, R., Stark, H., Fries, C. A., Reddy,
wall VCA and intestinal transplant due to Crohn’s disease. S., Allan, P., ... & Tempelman, T. (2020). Abdominal Wall
Left, Pretransplant (TPN-dependent with multiple fistu- Transplantation: Indications and Outcomes. Current
las); middle and right, 9 months post-transplant Transplantation Reports, 1–12)
32 Transplant and Plastic Surgery 501
then be used to supply the abdominal wall, anas- These followed the first initial transplant in
tomosing the donor and recipient epigastric ves- 1969 in Belgium, in which the patient was main-
sels. Temporary revascularization of the tained on immunosuppression for 8 months fol-
abdominal wall VCA is also possible via the lowing his transplant but eventually succumbed
recipient’s ulnar or radial arteries [33]. This is a
to a recurrence of a stromal tumor upon which
particularly valuable technique for fragile immunosuppression was stopped [36].
patients to reduce operative time and enable As in almost all VCAs, the technical details of
simultaneous intestinal transplant and abdominal the procedure are dependent on the tissue trans-
wall perfusion. The abdominal wall VCA can planted and the initial defect [37]. Anastomoses
then be pedicled for 4–6 weeks on the ulnar or are reported between the donor right superior
radial arteries until the transplant establishes vas-
thyroid and recipient superior thyroid artery. The
cular supply from the recipient’s adjacent abdom- donor right brachiocephalic vein is anastomosed
inal wall, when they can be divided. with the recipient internal jugular vein.
Alternatively, the donor right internal jugular
vein was anastomosed with the recipient’s com-
Key Point
mon facial vein in another case. Additional anas-
For fragile patients, revascularization of tomoses can be performed between the inferior
the abdominal wall transplant is possible thyroid arteries and transverse cervical arteries,
via the recipient ulnar or radial arteries; the the middle thyroid vein, and the left jugular vein
transplant can reestablish vascular supply dependent on the recipient anatomy.
from the adjacent abdominal wall, and the Nerve reinnervation, leading to potential nor-
pedicle can then be divided after 4–6 weeks mal phonation in speech following transplant, is
post-transplant. paramount [38]. This is dependent upon neuror-
rhaphies between the superior laryngeal nerves
of the donor and recipient and recurrent laryngeal
Currently, 46 abdominal wall transplants have nerves of the donor and recipient.
been performed [34]. Further, standardized qual- The outcomes of laryngeal transplant have
ity of life assessment of these patients is neces- been dramatic, including one patient stating his
sary. So far, there has been no evidence of first vocal words in 20 years only 3 days follow-
enhanced immune rejection of intestinal or solid- ing surgery [39]. Cough reflex returned at
organ transplants among these patients. In fact, 3 months postoperative. Sixteen months follow-
the skin of the abdominal wall may provide an ing surgery, objective measures of phonation in
additional monitoring sentinel mechanism to this patient were near normal levels. The other
assess rejection of the underlying solid organ or two patients also reported improvement in qual-
intestinal transplant. However, there is a dire ity life following the ability to phonate again.
need for enhanced data regarding the long-term Clearly, laryngeal transplant presents an opportu-
outcomes of these transplants. nity to dramatically improve quality of life in
patients who are unable to independently
phonate.
32.7 Laryngeal Transplant
successful face and hand transplants [40]. case of face and hand transplant, although hand
Ethical conundrums today involve more practi- transplants have occurred between mismatched
cal aspects of these procedures. This includes genders with similar-sized hands. These addi-
whether age and gender-mismatched transplants tional concerns, in addition to the immunological
are acceptable or whether it is permissible to matching also necessary in solid-organ trans-
perform face transplants on blind individuals or plant, lead to fewer acceptable donors for a
children [41]. Both uterine and penile trans- recipient.
plants invoke additional ethical controversies
and risk-benefit analyses, such as whether these
transplants should be offered to gender reas- 32.10 Nerve Regeneration
signment patients. The need for lifelong long
immunosuppression raises concerns as to what Unlike solid-organ transplant, VCA outcomes
functional and aesthetical gains justify the risk not only are dependent on reperfusion of tissue
of long-term immunosuppression. and successful immunosuppression but also rely
on nerve regeneration for functional outcomes
[45]. The often variable return of motor and sen-
32.8.2 Recipient Screening sory function following VCA is ultimately depen-
dent on the success of nerve regeneration.
As in solid-organ transplant, pretransplant psy- Although current suture repair techniques have
chological screening of recipients is a topic of resulted in positive outcomes in both hand and
utmost importance. As illustrated in this chapter face transplant, there is still immense opportunity
through failures in long-term VCA procedures, for improvement in both quality and timing of
recipient investment in the success of the nerve regeneration. This includes investigation
transplant is vital [42, 43]. A full understanding into the effect of immunosuppression on nerve
of the risk of immune rejection is absolutely cru- regeneration, particularly of tacrolimus, which
cial. A transplant psychiatrist is a vital member has demonstrated positive effects on enhancing
on the VCA team in both pretransplant screening regenerative capacity [46]. Tacrolimus has been
and post-transplant follow-up. Furthermore, shown to enhance the effects of nerve growth fac-
social support structures are important to the tors by increasing cellular sensitivity to growth
long-term success of VCA patients. factors as well as reducing local inflammatory
response. Furthermore, research in the utilization
of exogenously delivered neurotrophic factors to
Key Point enhance peripheral nerve regeneration are also
Psychosocial screening in VCA recipients crucially relevant to the field of VCA [47, 48].
is absolutely essential, as is the involve- The effects of electrical stimulation, including
ment of a transplant psychiatrist on the intraoperative direct muscle stimulation or stimu-
VCA team. lation of the proximal nerve stump, also appear
promising in enhancing peripheral nerve regen-
eration [49].
32.11 V
irtual Surgical Planning
and 3D-Printed Guides Key Point
We recommend a close working relation-
Three-dimensional computed tomographic ship with biomedical engineers, whom we
(CT) imaging, computer modeling, and virtual find crucial to the VCA team in the plan-
surgical planning (VSP) offer practical tools ning of these surgeries and creation of
for VCA (Fig. 32.5). Virtual surgical planning 3D-printed surgical guides.
has demonstrated benefits in surgical accuracy
and in reducing operative time in complex
reconstructive procedures [50]. VCA proce-
dures are extremely intricate procedures in
which virtual surgical planning can provide 32.12 Immunosuppression
utmost guidance intraoperatively. This
includes the planning of osteotomies outside The risk-benefit ratio of VCA is heavily influ-
of the operating room, in a controlled environ- enced by the negative effects of immunosuppres-
ment in which the recipient defect and donor sion and the non-life-saving nature of these
anatomy can be strategically assessed [51]. transplants. Current protocols at most VCA cen-
This is particularly important in both face and ters are based on solid-organ transplant immuno-
hand transplant, as our team found it essential suppression protocols [53]. This include
in performing a face transplant. Virtual surgi- induction with polyclonal antithymocyte globu-
cal planning can lead to 3D printed osteotomy lins or anti-interleukin-2 monoclonal antibody
guides, which then leads to bony cuts created preparations, followed by maintenance immuno-
in the ideal location for both arm length match- suppression with a calcineurin inhibitor (com-
ing to the contralateral arm (in the case of monly Tacrolimus), antiproliferative agent
hand transplant) or ideal planned facial plating (commonly mycophenolate mofetil), and cortico-
(in the case of face transplant). Furthermore, steroids. Acute rejection is common among VCA
intraoperative navigation can also be utilized patients and typically treated with oral or intrave-
if 3D-printed guides are not available to direct nous steroids, T cell-depleting agents, and in
the location of osteotomies, and mixed reality some program also with topical corticosteroids or
also provides another innovative modality to tacrolimus. As expected, as we have seen longer
aid in surgical decision-making [52]. follow-up of VCA recipients, as with other solid
Fig. 32.5 Preoperative virtual surgical planning of osteotomy location then enables the 3D printing of osteotomy
guides for a more efficient surgery and ideal reconstruction (©SamirMardini 2021. All Rights Reserved)
504 M. Suchyta et al.
update from the Louisville hand transplant program. 34. Giele H, Vaidya A, Reddy S, Vrakas G, Friend
Hand Clin. 2011;27(4):417–21. P. Current state of abdominal wall transplantation.
15. Azari KK, Imbriglia JE, Goitz RJ, et al. Technical Curr Opin Organ Transplant. 2016;21(2):159–64.
aspects of the recipient operation in hand transplanta- 35. Krishnan G, Du C, Fishman JM, et al. The cur-
tion. J Reconstr Microsurg. 2012;28(1):27. rent status of human laryngeal transplantation in
16. Jensen SE, Butt Z, Bill A, et al. Quality of life consider- 2017: a state of the field review. Laryngoscope.
ations in upper limb transplantation: review and future 2017;127(8):1861–8.
directions. J Hand Surg Am. 2012;37(10):2126–35. 36. Farwell AFBDG. Laryngeal transplantation. Adv
17. Petruzzo P, Lanzetta M, Dubernard J-M, et al. Neurolaryngol. 2020;85:125.
The international registry on hand and com- 37. Khariwala SS, Lorenz RR, Strome M. Laryngeal
posite tissue transplantation. Transplantation. transplantation: research, clinical experience, and
2010;90(12):1590–4. future goals. Paper presented at: Seminars in Plastic
18. Alolabi N, Augustine H, Thoma A. Hand transplanta- Surgery. 2007.
tion: current challenges and future prospects. Transpl 38. Lorenz RR, Hicks DM, Shields RW Jr, Fritz MA,
Res Risk Manag. 2017;9:23–9. Strome M. Laryngeal nerve function after total laryn-
19. Siemionow M. The decade of face transplant out- geal transplantation. Otolaryngol Head Neck Surg.
comes. J Mater Sci Mater Med. 2017;28(5):64. 2004;131(6):1016–8.
20. Pomahac B, Gobble RM, Schneeberger S. Facial and 39. Strome M, Stein J, Esclamado R, et al. Laryngeal
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Med. 2014;4(3):a015651. Med. 2001;344(22):1676–9.
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Pomahac B. Functional outcomes of face transplanta- Mardini S. Ethicists’ opinions regarding the per-
tion. Am J Transplant. 2015;15(1):220–33. missibility of face transplant. Plast Reconstr Surg.
22. Siemionow M, Gharb BB, Rampazzo A. Pathways 2019;144(1):212–24.
of sensory recovery after face transplantation. Plast 41. Caplan AL, Parent B, Kahn J, et al. Emerging ethi-
Reconstr Surg. 2011;127(5):1875–89. cal challenges raised by the evolution of vascular-
23. Rasper AM, Terlecki RP. Ushering in the era of penile ized composite allotransplantation. Transplantation.
transplantation. Transl Androl Urol. 2017;6(2):216. 2019;103(6):1240–6.
24. Hu W, Lu J, Zhang L, et al. A preliminary report 42. Kumnig M, Jowsey-Gregoire S. Preoperative psy-
of penile transplantation: part 2. Eur Urol. chological evaluation of transplant patients: chal-
2006;50(5):1115–6. lenges and solutions. Transplant Res Risk Manag.
25. Bateman C. World’s first successful penis trans- 2015;7:35–43.
plant at Tygerberg Hospital. S Afr Med J. 43. Jowsey-Gregoire S, Kumnig M. Standardizing psy-
2015;105(4):251–2. chosocial assessment for vascularized composite
26. Brännström M. Uterus transplantation. Curr Opin allotransplantation. Curr Opin Organ Transplant.
Organ Transplant. 2015;20(6):621–8. 2016;21(5):530–5.
27. Testa G, Koon E, Johannesson L, et al. Living donor 44. Huang A, Bueno EM, Pomahac B. A single cen-
uterus transplantation: a single center’s observations ter’s experience with donation of facial allografts
and lessons learned from early setbacks to technical for transplantation. Vascular Compos Allotransplant.
success. Am J Transplant. 2017;17(11):2901–10. 2015;2(4):80–7.
28. Brännström M, Johannesson L, Bokström H, et al. 45. Suchyta MA, Sabbagh MD, Morsy M, Mardini S,
Livebirth after uterus transplantation. Lancet. Moran SL. Advances in peripheral nerve regeneration
2015;385(9968):607–16. as it relates to VCA. Vascular Compos Allotransplant.
29. Jones B, Saso S, Bracewell-Milnes T, et al. Human 2016;3(1–2):75–88.
uterine transplantation: a review of outcomes from 46. Saffari T, Bedar M, Zuidam J, et al. Exploring the
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30. Daolio J, Palomba S, Paganelli S, Falbo A, Aguzzoli 47. Terenghi G. Peripheral nerve regeneration and neuro-
L. Uterine transplantation and IVF for congenital or trophic factors. J Anat. 1999;194(1):1–14.
acquired uterine factor infertility: a systematic review 48. Gordon T. The role of neurotrophic factors in nerve
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31. Park SH, Eun S-C. Abdominal wall transplant sur- regeneration with electrical stimulation. Neurol Res.
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2020;36(07):522–7. 51. Momeni A, Chang B, Levin LS. Technology and vas-
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52. Brown EN, Dorafshar AH, Bojovic B, et al. Total 55. Plock JA, Schnider JT, Schweizer R, et al. The influ-
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Part VI
Aesthetic Plastic Surgery
Aesthetic Plastic Surgery
33
Klinger Marco, Battistini Andrea,
Rimondo Andrea, and Vinci Valeriano
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 509
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_33
510 K. Marco et al.
o ccupying space, pushes the glandular tissue for- removing fluid through the filling tube. This gives
ward, increasing the overall breast volume. the patient the opportunity to correct any error in
According to the American Society of Plastic the dimensions initially chosen.
Surgeons, more than 347,000 women between 19 The surface of the breast implants can be clas-
and 34 years old undergo breast augmentation sified as follows:
each year.
–– Macro-textured prosthesis, with rough
The choice of the implant highly depends on
surface.
the patient’s preferences and body type. If
–– Micro-textured prosthesis, with poorly rough
patients desire naturally looking breasts, anatom-
surface.
ical implants will be the best choice since they
–– Smooth prosthesis. They present a higher risk
have a teardrop shape which appears to be really
of rotation and capsular contracture. Among
similar to natural breasts creating a smooth upper
these, “nanotextured” implants should be
pole and overall non-operated look.
included. The latter are characterized by a
Otherwise, if the patient’s main concern is
minimally rough, almost smooth surface. The
about upper pole fullness, then round implants
advantages are that they allow to reduce the
can be the best option.
length of the skin incisions necessary for their
Breast implants are made of an envelope (sili-
introduction, and by implanting them, we
cone or polyurethane) which can alternatively
obtain a softer and more natural consistency.
contain silicone gel or physiological solution.
The silicone gel prosthesis is the most used The incision for implant introduction can be
and confers the characteristics of consistency, placed at the level of the axilla (armpit), areola,
softness, and mobility, typical of the breast. or lower breast fold (inframammary fold). In
These implants are subjected to very careful tests general, all breast augmentations are minimally
to establish their safety and efficacy. Cohesive invasive procedures, involving incisions that are
silicone gel implants have the great advantage only a few centimeters in length.
that, in case of tearing, the gel inside does not The inframammary approach, often called
spread throughout the body. They even reduce the crease incision, is the most common
the risk of postoperative wrinkling. The cohesive approach for implant placement. The incision is
silicone gel gives a feeling of naturalness to the performed in the fold under the breast, called
breast and also maintains normal body tempera- the inframammary fold, where the breast meets
ture; therefore, it is now considered the most suit- the chest wall.
able material. Silicone breast implants do not The periareolar and inferior emi-areolar inci-
interfere with breastfeeding or with the sensitiv- sions consist in an incision around the entire
ity and specificity of any diagnostic test (mam- darker outer edge of the areola concerning the
mography, ultrasound, biopsies, etc.). former and a semicircle on the lower half of the
The second type of prosthesis are saline areola for the latter. The implant is then inserted
implants, which are full of water and salt. The through the incision and placed into position.
main quality of this type of filling is the fact that The transaxillary approach requires placing an
it’s harmless: in case of spill, the solution is incision in the crease of the armpit, through
absorbed by the body. This type of implant has which the surgeon creates the implant pocket and
the advantage of being inserted into the patient’s inserts the prosthesis. The implant is filled with
body empty and folded. Another advantage is saline after it has been placed in the chest pocket.
their size. Indeed, saline implants are the only Another possibility is represented by the
breast implants that can be filled through a umbilical approach, although it is difficult and
removable tube, adjusting the size by adding or rarely used.
33 Aesthetic Plastic Surgery 511
Potential surgical complications could be ness in the affected breast or changes in the breast
divided into pre- and intraoperative complica- contour.
tions and further into early and late postoperative Capsular contracture is the most common
complications. complication following implant-based breast sur-
Preoperative and intraoperative complications gery, and it is one of the most common reasons
derive from poor planning (wrong choice of the for a second surgery. Therefore, it is important to
surgical access, incorrect measurement) or poor understand why this happens and what can be
surgical technique (over-dissection of the implant done to reduce its incidence.
pocket, implant malpositioning, excessive Capsular contracture is caused by an exces-
bleeding). sive fibrotic reaction to a foreign body (the breast
Early postoperative complications include implant), and it has an overall incidence of
hematoma, seroma, infection, and implant 10.6%. It can appear as an early capsular contrac-
malpositioning. ture (few months after surgery or years later).
Late postoperative complications include Risk factors include the use of smooth (vs.
infection, seroma, capsular contracture, distor- textured) implants, a subglandular (vs. submus-
tions, implant visibility, implant malposition, cular) placement, use of a silicone (vs. saline)
implant rippling, wrinkling and palpability, filled implant, and previous radiotherapy to the
implant rupture, and poor scar healing. breast.
Rupture is a long-recognized complication of Capsular contracture is graded by the Baker
all breast implants that can be caused by a strong scale and follows these criteria:
impact to the breast, surgical error, cracks that
• Grade I: The breast is soft and appears normal,
develop over time, excessive capsular contrac-
and the capsule is flexible.
ture, or, rarely, pressure exerted during a mam-
• Grade II: The breast looks normal but is some-
mogram. Both saline and silicone implants are
what hard to the touch.
equally vulnerable to implant rupture.
• Grade III: The breast is hard and has some dis-
A saline implant rupture is generally easy to
tortion caused by contracture, or instead, it
detect because the saline fluid leaks out over a
may be significantly distorted, and it can
short period, so the breast appearance changes
appear with a rounded shape, or the implant
quickly and noticeably; it suddenly looks smaller
may be tilted upward.
and deflated. Some patients experience breast
• Grade IV: Contracture looks more advanced
pain, changes in nipple sensation, or skin tender-
than grade III, often causing severe hardening
ness. They may even show signs of capsular
of the capsule and pain.
contracture.
Unfortunately, silicone implant ruptures are The surgical correction of capsular contrac-
more difficult to detect because the silicone gel ture is known as capsulectomy, a procedure
does not rapidly leak from the implant but gradu- where all or a part of the thickened capsule
ally seeps into the breast pocket, and it remains in around the breast implant is removed and, at the
the body, sometimes spreading to nearby lymph same time, a replacement of the breast implant is
nodes. Some women experience pain or tender- required.
512 K. Marco et al.
children, and breastfeeding and at the same time increase in size of the mammary gland. In the
to restore their youthful shape. first case, the procedure for the correction of
To achieve the desired result, the excess skin gynecomastia is carried out removing excess adi-
must be removed, and the nipple has to be pose tissue through liposuction. Instead, if the
replaced; the outcoming scars, consistently with gynecomastia is due to an increase of the
the amount of skin removed, can be of three mammary gland, it is necessary to remove the
types: glandular tissue surgically by a small cutaneous
incision at the periareolar site, on the border
• Periareolar (around the perimeter of the whole
between the dark skin of the areola and the pale
areola).
skin, in order to perform a subcutaneous
• Periareolar and vertical (in addition to the scar
mastectomy.
around the areola, a vertical scar from the are-
ola to the inframammary sulcus).
• Inverted-T scar (in addition to the second type
33.2 Rhinoplasty
it presents a further scar in the inframammary
sulcus). This type of mastopexy is performed
Rhinoplasty is among the most commonly per-
when the excess skin to be removed is
formed aesthetic surgical procedures in plastic
considerable.
surgery that enhances facial harmony and the
All these techniques can be used with or with- proportions of the nose and corrects impaired
out employment of breast implants. breathing caused by structural defects of the
nose.
Patients seek rhinoplasty for different reasons:
33.1.4 Gynecomastia Correction nose reconstruction after an injury, improvement
of airway function, correction of birth defects,
Gynecomastia is defined as the pathological and aesthetic reasons.
development of one or both male mammary Rhinoplasty can modify nose size in relation
glands. This condition is common in elderly men, to facial balance and harmony, straighten a
but it is also observed in young people. crooked nose, refine or reduce a bulbous nasal
The volume of the breasts can increase for dif- tip, correct nasal tip asymmetry, correct nostrils
ferent reasons. Oftentimes, the cause of gyneco- asymmetry and position, and correct a nasal
mastia is due to a patient’s overweight, hormonal bump, and in case of a secondary rhinoplasty, we
alterations, or the intake of certain drugs such as can revise poor nose job results.
anabolic steroids. There are two different approaches to rhino-
Many times, the causes may not be identifi- plasty: open rhinoplasty and closed rhinoplasty.
able, and the problem is limited only to aesthetic Open rhinoplasty (external rhinoplasty) is per-
damage. Gynecomastia often involves both formed by making a small incision on the colu-
breasts, but sometimes can be unilateral, with fur- mella, called trans-columellar incision, and it
ther aesthetic discomfort, also due to asymmetry. allows plastic surgeons to open the skin of the
Gynecomastia may be defined as an excessive nose or unveil the nose.
development of the mammary gland (real gyne- On the other hand, concerning a closed rhino-
comastia), an excess of fat deposited in this plasty approach (endonasal rhinoplasty), two
region (false gynecomastia), or an excess of both incisions are made within the inside of the nose
mammary gland and adipose tissue (mixed gyne- (inside the nostrils). It is through these incisions
comastia). They can be determined through med- that all the nasal defects are addressed. In this
ical consultations and ultrasound scan. way, all the necessary incisions remain com-
Surgery for gynecomastia differs whether the pletely hidden within the nostrils.
increase in volume of the breasts is due to an Each approach has its advantages and disad-
excess of adipose tissue or it is associated with an vantages: the closed technique takes a shorter
514 K. Marco et al.
time to be completed, it is less invasive, it leaves the cartilages that will be addressed in the sur-
no visible scars, and it causes less swelling result- gery. An open rhinoplasty gives plastic surgeons
ing in a shorter recovery time. On the other hand, the ability to manipulate and alter nasal shape
as there is limited visibility of the tissues and car- with more control and precision. Moreover, the
tilages, the surgeon can make limited changes stabilization of the nose after surgery is easier in
with limited precision; it is a “blind” procedure. open rhinoplasty with respect to closed
In addition, following surgery, the incisions can rhinoplasty.
weaken the nasal structure, undermining struc- On the other side, open rhinoplasty is longer
tural stability of the nose. and more invasive, so recovery time will be a lit-
Concerning open rhinoplasty, the main tle longer, and it takes more time for swelling and
advantage is that it allows better visualization of bruising to disappear.
moved back and forth, allowing the surgeon to erate fat accumulation. Nowadays, three types of
pull out fat. abdominoplasty are widespread:
–– Laser-assisted liposuction: a technique that
uses a laser to break down fat, and later a can- • Mini abdominoplasty: performed for cases in
nula is employed to remove fat. which only an aesthetic correction is needed.
–– Tumescent liposuction: the most commonly A small amount of skin and adipose tissue
used procedure that involves the infiltration of involving the area below the navel is removed.
tissues prior to liposuction with a sterile solu- This technique involves a single incision just
tion in order to make the area stiff and swol- above the pubic mound, through which the
len. Then, a cannula is inserted and connected surgeon will tighten loose muscles and remove
to a vacuum which will aspirate the fat. excess skin to restore a smooth, flat abdominal
–– Liposuction with radiofrequency: the thermal wall. It does not involve any intervention on
energy generated from the radio waves melts the navel.
the fat tissue, which is then aspirated. • Complete abdominoplasty: in this case, the
maximum amount of skin and adipose tissue
Liposuction is normally done for cosmetic over the abdominal muscle is removed.
purposes, but it is sometimes used to treat certain Through a horizontal or u-shaped incision
conditions such as lymphedema, lipodystrophy above the pubic mound, the surgeon will
syndrome, extreme weight loss after obesity, or remove excessive skin and tighten the abdom-
lipomas. inal muscles. The navel is usually detached
Like any major surgery, it carries risks of and repositioned on the new abdominal wall.
bleeding, infection, and an adverse reaction to • Torsoplasty: a circumferential abdomino-
anesthesia, but complications may also include plasty used to remove excess cutaneous and
pulmonary embolism, fluid collection (seroma), subcutaneous tissue of the lumbar and dorsal
and hematoma. areas.
The maximum volume of adipose tissue that is
An abdominoplasty carries various risks,
recommended to be removed is 6% of the
including:
patient’s weight.
• Fluid accumulation beneath the skin (seroma).
Drainage tubes which are left in place after
33.4 Abdominoplasty surgery can help reduce the risk of excess fluid
accumulation.
Abdominoplasty, also known as a “tummy tuck,” • Poor wound healing. Sometimes, areas along
is designed to improve the shape and tone of the the incision line heal poorly or begin to
abdominal region, by removing excess fat and separate.
skin. The result is a flatter and firmer abdomen. • Unexpected scarring. The incision scar is per-
Even patients with normal body weight and manent but is placed along the hidden bikini
proportion can present an abdomen that protrudes line. The length and visibility of the scar var-
or is characterized by looseness and sagginess. ies from person to person.
The most common causes of this condition • Tissue damage or death. During a tummy
include aging, genetics, pregnancy, prior surgery, tuck, fat tissue in the abdominal area might get
and significant fluctuations in body weight. damaged or die. Smoking increases this risk.
Abdominoplasty allows also to correct Depending on the size of the area, tissue might
abdominal wall defects (hernias, diastasis heal on its own, or it may require a surgical
recti, etc.). touch-up procedure.
There are several types of abdominal plastic • Changes in skin sensation. During a tummy
surgeries; it is possible either to remove large tuck, the repositioning of abdominal tissues
amounts of fat and excess skin or to correct mod- can affect the nerves and consequently sensi-
516 K. Marco et al.
tivity in the abdominal area, and, less fre- A mini-brachioplasty can sometimes be per-
quently, it may affect also the upper thighs. formed although in this case the incision is con-
cealed in the armpit area.
Significantly hanging skin usually requires a
33.5 Thighplasty full brachioplasty in which an elliptical piece of
skin and fat is removed from the back of the arm,
Thighplasty (thigh lift) is a procedure used to placing the scar toward the chest wall, so that it
tighten and improve the overall appearance of will be concealed.
thighs. Candidates for this procedure present Once the excess tissue is removed, the sur-
with very loose skin in the thigh that has become geon achieves a more youthful contour to the arm
less elastic, or they have thighs with a saggy, re-establishing natural lines and anatomy.
dimpled, or flabby appearance. A thigh lift can
reduce sagging in the inner or outer thigh. It is
often a procedure performed on patients who 33.7 Gluteoplasty (Buttock Lift)
have massive weight loss.
The surgery takes place under general anes- Excess skin and fat from aging or after dramatic
thesia or spinal anesthesia. The procedure weight loss in the gluteal area can be improved
involves incisions extended from the inguinal with a buttock lift, a procedure that, in the last
region to the inner face of the root of the thigh 10 years, has become very popular around the
and the removal of excess skin. Sometimes, it is world. Patients can consider this procedure when
advisable to add a longitudinal scar of a few they have loose and drooping skin in the but-
centimeters along the most hidden medial face tocks, if they recently experienced significant
of the thigh in order to obtain a better correc- weight loss and feel uncomfortable and if excess
tion and a better skin tone of the whole region. skin causes mobility problems.
The skin is then stretched upward and anchored A durable augmentation of the gluteal region is
with deep stitches to the underlying tissues. achieved either by placing silicone implants (simi-
Permanent scars are obtained but hidden in the lar to breast implants) under the gluteus muscle or
inguinal fold and covered by a normal slip. by autologous adipose tissue graft (lipofilling).
In the case of a circumferential lift, the exci- An incision is performed in the intergluteal
sion affects the overall circumference of the thigh fold to emplace the prosthesis within each glu-
with a final scar corresponding to the circumfer- teus maximus muscle. This positioning reduces
ential incision. many postoperative problems previously derived
from a deeper implantation of the prostheses.
Then, surgery is completed with a liposculpture
33.6 Brachioplasty or lipofilling to reshape harmoniously the con-
tour of the buttocks.
Arm lift, also known as brachioplasty, is an aes- Depending on the shape the surgeon wants to
thetic surgical procedure that aims to improve achieve, the choice is between oval prostheses
the appearance of the inner portion of the upper (anatomical) or elongated implants that could be
arms. This type of surgery is often performed replaced intentionally or inevitably because of
after bariatric surgery or massive weight loss: the occurrence of complications even after a few
ideal candidates also have enough loose skin or many years following the first surgery.
and elasticity to allow a good outcome. Like any other type of major surgeries, it car-
During an arm lift, excess skin and fat are ries various risks including fluid accumulation
removed in the region between the armpit and the beneath the skin (seroma), poor wound healing,
elbow. scarring, and changes in skin sensation.
33 Aesthetic Plastic Surgery 517
lage. The major advantage of cutting technique tions of surgical fat removal: increase of adiponec-
is long-term stability of the results. Disadvantages tin plasma levels after reduction mammaplasty and
abdominoplasty. Ann Plast Surg. 2016;76(6):700–4.
include disruption of cartilaginous support and 4. Klinger M, Giannasi S, Klinger F, Caviggioli F,
creation of contour irregularities. Bandi V, Banzatti B, et al. Periareolar approach in
• Cartilage sparing, a technique that avoids full- oncoplastic breast conservative surgery. Breast J.
thickness incisions, attempts to create more 2016;22(4):431–6.
5. Brown RH, Chang DK, Siy R, Friedman J. Trends in
effective angles and curls in the cartilage in the surgical correction of gynecomastia. Semin Plast
order to decrease the incidence of contour Surg. 2015;29(2):122–30.
irregularities and to maintain the structural 6. Cafferty A, Becker DG. Open and closed rhinoplasty.
support of the cartilage. Clin Plast Surg. 2016;43(1):17–27.
7. Klinger M, Caviggioli F, Forcellini D, Bandi V,
Maione L, Vinci V, et al. Primary nasal tip sur-
The most commonly used techniques include gery: a conservative approach. Aesthet Plast Surg.
the Mustardè technique, performed for helix cor- 2012;36(3):485–90.
rection, and the Furnas technique, used for prom- 8. Pereira-Netto D, Montano-Pedroso JC, Aidar ALES,
Marson WL, Ferreira LM. Laser-assisted liposuc-
inent concha correction. tion (LAL) versus traditional liposuction: systematic
review. Aesthet Plast Surg. 2018;42(2):376–83.
9. Klinger M, Klinger F, Battistini A, Lisa A, Maione L,
Take-Home Messages Caviggioli F, et al. Secondary treatment of cleft lip
• Aesthetic plastic surgery is performed correction sequelae with percutaneous needleotomy,
to reshape normal structures of the body autologous fat grafting, and local flaps: an integrated
in order to improve the patient’s appear- approach. J Craniofac Surg. 2021;32(2):642–6.
10. Matarasso A, Matarasso DM, Matarasso
ance and self-esteem. EJ. Abdominoplasty: classic principles and technique.
• The physical defects can be genetic, or Clin Plast Surg. 2014;41(4):655–72.
they may arise either as a consequence 11. Bertheuil N, Carloni R, De Runz A, Herlin C, Girard
of the physiological aging process or P, Watier E, et al. Medial thighplasty: current concepts
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Plastic Surgery in the COVID-19
Era
34
Marcasciano Marco, Kaciulyte Juste,
and Casella Donato
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 521
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1_34
522 M. Marco et al.
a comprehensive understanding of breast cancer while ensuring high standards of care and the
treatment, leading to wider offer of reconstruc- continuity of their surgical activity.
tive options and higher rates of successful
outcomes.
34.3 Learning and Sharing
Knowledge While Facing
Key Point
the COVID-19 Pandemic
In the battle against breast cancer and
COVID-19, breast surgery is evolving, and Besides radical changes in personal and working
plastic surgeons must adapt, develop new daily routine, medical students’ didactic and resi-
skills, and reshape themselves in a new and dents’ training programs underwent important
comprehensive role. modifications, to respond and adapt to the pan-
The pandemic that has hit the world demic events. Institutions from all around the
should make us realize how suddenly our world reacted implementing online platforms to
lives and profession can change and enable keep on delivering info and “education.” Webinars
us to reflect on the true values that must and online exams represent modern and easy-to-
guide us in the future [24]. Following the apply solutions, even if limited to theoretical
Darwinian sentence: “it is not the strongest sharing. Residents belonging to surgical areas
of the species that survives, nor the most report that their training was somehow weak-
intelligent. It is the one that is most adapt- ened, due to the reduced number of surgical pro-
able to change” [34]. cedures [37].
In Zingaretti N. et al.’s [37] study, a question-
naire that investigated how practical and theatri-
While all efforts are aimed at stopping the cal activity has changed in pandemic was
pandemic, other serious and life-impacting dis- submitted to all Italian plastic surgery residents.
eases continue to affect the population. Plastic Indeed, the majority of them reported lack of
surgeons are “physicians”, prior to being “sur- training during this period as a detrimental factor
geons”. Moreover, the peculiarity of our disci- for their professional growth. It is mandatory to
pline offers the unique perspective of dealing find alternative ways to keep on sharing knowl-
with all kinds of patients and care teams, fueling edge and developing skills while maintaining a
the development of ingenuity and new skills to good quality of the educational targets.
actively participate and contribute to the In the last years, the classic learning
COVID-19 response. For example, special Halstedian model of “see one, do one, teach one”
wound management expertise was requested in changed into a modern proficiency-based train-
dealing with facial wounds caused by personal ing, thanks to new technological advancements
protective equipment (PPE), in healthcare pro- [38]. Online videos shared on social media por-
viders [35]. tals are gaining importance, as an easy and effec-
While other medical specialists fight in the tive way to share information in the medical
frontline in the worldwide battle against field, and plastic surgeons appear to be particu-
COVID-19, plastic surgery shall not be consid- larly fond of their use. Indeed, due to their prac-
ered of secondary importance. In the absence of tice with social media, they are in a unique
a “gold standard” treatment, the rapid develop- position to provide medically sound information
ment of a safe and effective vaccine is consid- about COVID-19 to their followers. Despite the
ered the most promising way to control the existence of some ethical dilemma on the appro-
pandemic [36]. priate use of social media in plastic surgery, in
In such hazardous times, plastic surgeons the actual context, it appears ethically justified as
must adapt and consolidate their role, in order to it benefits the public and demonstrates commit-
keep on offering full support to other disciplines ment to professional virtues [39].
34 Plastic Surgery in the COVID-19 Era 527
A rhinoplasty, 513
ABCDE (Asymmetry, Border, Color, Diameter, Evolving thighplasty, 516
or changing) criteria, 358, 369 Alanine aminotransferase (ALT), 292
Abdominal wall defects, 401 ALT flap, 81, 82, 142
acquired defects, 407, 408 Allografts, 130, 437
classification, 405 Alveolar bone grafting, 191
congenital defects, 406 Ambiguous genitalia, 227
full thickness defects, 409 American Joint Committee on Cancer (AJCC), 375
integument, 402 Amputation, 266
lymphatics, 404, 405 Anastomosis, 481, 482, 485
myofascial system, 403 Angiosarcomas, 373
nerves, 405 Angiosome, 105
postoperative, 409 Anotia, 183
surgical treatment, 410–416 Anterior plagiocephaly, 175
vessels, 405 Anterograde (orthograde) flow, 112
Abdominal wall transplant, 500 Antisepsis, 40
Abdominoplasty, 515 Aortobifemoral dacron prosthesis, 158
Abrasion, 242 Apert/Poland syndrome, 178, 193, 194, 210
Absorbable and non-absorbable sutures, 45 Apical hypospadias, 231
Acellular dermal matrix (ADM), 385 Apligraf®, 57
Acellular human processed nerve allografts (ANAs), 71 Apocrine units, 8
Acellular products, 72 Arc of rotation, 106
Acquired abdominal wall defects, 402, 406 Areola reconstruction, 398
Acute burn trauma management, 293, 294 Arterial ulcers, 28, 29
Acute radiation dermatitis, 315 Artery, 129
Adipose-derived stem/stromal cells (ADSCs), 463 Arthrogryposis, 215
Adipose stem cells (ASCs), 67 Aspartate aminotransferase (AST), 292
Adipose tissue bioactive factors (ASCs), 67 ASPS Fat Graft Task Force, 68
Adnexa, 7 Atrophic scars, 20
grafts, 65–66 Atypical fibroxanthoma (AFX), 372
Advancement flap, 349 Autografts, 62, 263, 436, 437
Aesthetic surgery, 509 Autologous dermal grafts, 66
abdominoplasty, 515 Autologous tissue, 388
augmentation mammoplasty, 510, 511 Axonotmesis, 432
blepharoplasty, 519 Axons, 128
brachioplasty, 516
breast reduction, 512
buttock lift, 516 B
face lift, 517 Back of the hand, 266
lipofilling, 519 Bacterial biofilm, 51, 52
mastopexy, 513 Bardach, 190
otoplasty, 520 Basal cell carcinoma (BCC), 343–345
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 531
M. Maruccia, G. Giudice (eds.), Textbook of Plastic and Reconstructive Surgery,
https://doi.org/10.1007/978-3-030-82335-1
532 Index
Sathre-Chotzen and Jackson-Weiss syndromes, 178 microsurgical tissue reconstruction, 160, 161
Scaffolds, 466 muscle versus perforator flaps, 144
Scalpel, 41 perforator-to-perforator approach, 153, 154
Scaphocephaly, 175 revascularise “pure subdermal” flaps, 142
Scars, 297 Soft tissue defect, 149, 159
classification, 21–22 Solitary vascularized compound flaps, 116
formation, 15 Spider bites, 245
Schwann cells, 430 Split-thickness skin grafts (STSG), 61, 64, 297, 351
Schwannomas, 372 Squamous cell carcinoma (SCC), 346, 347
Scissors, 42 SRY gene, 225
Scrotoplasty, 453 Staging, 375
Sebaceous glands, 9 Standoli preputial island flap, 231–234
Secondary deformities, 191 Staphylococcus aureus, 32, 52
Secondary intention, 250 Staphylococcus epidermidis, 32, 52
Secondary wound healing, 16 Staples, 46
Sensate flap, 114 Static treatment, 439
Sentinel lymph node biopsy (SLNB), 361, 362, Steristrips, 46
364, 369 Stickler syndrome, 178, 180
Sepsis, 292 Stromal vascular fraction (SVF), 466
Serum imbibition, 63 Subcutaneous suture, 49
Severe burn injury (SBI), 288 Subcutaneous tissue, 11
SGAP flap, see Superior gluteal artery perforator Submucosal cleft palate, 174, 191
(SGAP) flap Supercharging, 112
Simple interrupted suture, 47 Superficial inferior epigastric artery (SIEA) flap, 388
Simple running suture, 47–48 Superior gluteal artery perforator (SGAP) flap, 36, 388,
Simple, stable fractures, 259 391
Simple wounds, 243 Superior laryngeal nerves, 501
Skin Super microsurgery, 108, 138, 485
dermis and nano-microsurgery, 78
mast cells, 11 Supramicrosurgery, 142
muscle, 11 Supra-thin ALT flap, 142, 143
nerve fibers, 11 Sural nerve graft, 71
subcutaneous tissue, 11 Surgery, 23
vasculature, 10 Surgical flap delay, 114
dermo-epidermal junction Surgical site infections (SSIs), 242
adnexa, 7 Suture, 250
apocrine units, 8 Suture materials, 39, 43–45
eccrine sweat glands, 7 Suture techniques
hair follicle, 8, 9 antisepsis, 40
nails, 10 closure materials
sebaceous glands, 9 alternative to suturing, 46
epidermis, 3 deep closure, 48–49
functions of, 12–13 horizontal mattress suture, 48
keratinocytes, 3–5 intradermal suture, 48
Langerhans cells, 6, 7 post-operative dressing, 49–50
melanocytes, 6 simple interrupted suture, 47
Merkel cells, 7 simple running suture, 47–48
and subcutaneous fat, 4 surgical needles, 45, 46
Skin grafts, 252, 352 suture material, 43–45
Skin tears, 245 vertical mattress suture, 48
Skin tension lines, 43 hand hygiene, 40
Smith’s classification, 230 preoperative shaving, 40
Snake bites, 245 surgical instruments, 41–42
Snodgrass one-stage repair, 234 tissue handling, 42–43
Snow-Littler procedure, 209, 219 Symphalangism, 212
Sodium alginate, 53 Syndactyly, 210, 220
Soft tissue coverage Syndromic craniosynostosis, 169, 178, 183, 193
“drive-through” algorithm, 156 Synkinesis, 497
ischemic limb salvage, 153, 154 Synovial sarcoma, 373
local versus free perforator flaps, 148, 149, 151 Synthetic materials, 211
Index 541
W
U Water displacement, 421
Ulnar longitudinal deficiency, 208, 219 Werner syndrome, 19
Ultra-high frequency ultrasound, 422 Wound closure, 250–253
542 Index
Wound dressing, 252, 253, 297 bite, sting and puncture, 243
Wound healing, 348 bee and wasp stings, 245
exuberant scars, 22–24 mammalian bites, 243–245
factors influencing snake bites, 245
local factors, 19–20 spider bites, 245
systemic factors, 19 clinical evaluation
hypertrophic scars, 20, 21 history, 245–246
insufficient scarring, 20 laboratory studies, 247
keloids, 20, 21 microbiological and histological evaluations, 247
massage and compression, 22 radiological imaging, 247
phases of, 16 wound assessment, 246, 247
hemostasis, 16, 17 crush injury, 242
inflammation, 16, 17 laceration, 242
proliferation, 16 treatment
proliferative stage of, 17 wound closure, 250–253
remodelling phase, 16, 18 wound debridement and preparation, 247–250
regeneration, 15
scar classification, 21–22
scar formation, 15 X
tissue integrity, 15 Xenografts, 62
types of, 16
typical atrophic scars, 20
Wounds, 51 Z
abrasion, 242 Z-plasty, 210, 299
acute injuries, 241 incision, 208