Operative Procedures in

Plastic, Aesthetic and

Reconstructive Surgery
EDITED BY
ARI S. HOSCHANDER • CHRISTOPHER J. SALGADO
WROOD KASSIRA • SETH R. THALLER
 Operative Procedures in
Plastic, Aesthetic and
Reconstructive Surgery
 Operative Procedures in
Plastic, Aesthetic and
Reconstructive Surgery
EDITED BY

ARI S. HOSCHANDER CHRISTOPHER J. SALGADO

UNIVERSITY OF MIAMI UNIVERSITY OF MIAMI
MILLER SCHOOL OF MEDICINE MILLER SCHOOL OF MEDICINE
MIAMI FL MIAMI FL

WROOD KASSIRA SETH R. THALLER

UNIVERSITY OF MIAMI UNIVERSITY OF MIAMI
MILLER SCHOOL OF MEDICINE MILLER SCHOOL OF MEDICINE
MIAMI FL MIAMI FL

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Dedications

Shira, your support, motivation, and love have Fu-Chan Wei, Steve Evans, Chris Attinger, and
made this possible. You inspire me daily. No words Samir Mardini, have made the most impact on
can express my gratitude for all you do. my academic surgical career; it is their influence
on my career that has given me the encouragement
Jacob, Ezra, and Levi, the greatest kids in the world.
to accomplish the editorial work for this magnifi-
Thank you for giving up some of our time together
cent book. Lastly, my mother, Margarita Salgado,
so that I could pursue this endeavor.
and father, Juan Salgado, have instilled in me the
Mordechai and Rebecca Hoschander, my parents importance of dedication, hard work, and educa-
who have given me everything, I thank you. tion; without this early teaching, this editorial
­process would not have been possible.
Mentors and Colleagues, the only way to repay you
for the knowledge and experience that you have
Christopher J. Salgado
given to me is to pass that education on to the next
generation of plastic and reconstructive surgeons.
For my mentors, who have taught me, and resi-
I hope this book will repay part of that debt.
dents, who inspire me every day.
Ari S. Hoschander
Wrood Kassira
I would first like to thank my family, who I love
To the center of my life: wife, Pat; and kids,
more than anything in this world. It is with their
Steven Cody and Alexandra Lee. They make it all
support that time was allowed to invest in this
worthwhile.
book, which I feel is a significant addition to any
plastic surgeon’s library. Second, my mentors
Seth R. Thaller
in plastic  surgery, Professors Hung-Chi Chen,
Contents

Foreword ix
Preface xi
Editors xiii
Contributors xv

Part 1  GENERAL RECONSTRUCTION 1

1 Skin grafting and dermal substitute placement 3

Giorgio Pietramaggiori, Saja S. Scherer-Pietramaggiori, and Dennis P. Orgill
2 Component separation 9
Harvey Chim, Karen Kim Evans, and Samir Mardini
3 Lower extremity reconstruction 17
Jeremy C. Sinkin, Christopher J. Salgado, Karen Kim Evans, Varsha R. Sinha, and
Kristin J. Blanchet
4 Chest wall reconstruction with pectoralis major muscle flaps 37
Ryan Ter Louw and Karen Kim Evans

Part 2  BREAST RECONSTRUCTION 49

5 Breast reduction: Inferior pedicle, wise pattern 51

Tarik M. Husain and Seth R. Thaller
6 Gynecomastia 59
Devra B. Becker, Shaili Gal, and Christopher J. Salgado
7 Implant-based breast reconstruction: Tissue expander placement after mastectomy 69
Ari S. Hoschander and John Oeltjen
8 Implant-based breast reconstruction: Exchange of tissue expander for permanent implant 75
Ari S. Hoschander, Michael P. Ogilvie, and John Oeltjen
9 Breast reconstruction with abdominal flaps 79
Maurice Y. Nahabedian and Ketan M. Patel
10 Nipple reconstruction 87
Dennis C. Hammond, Elizabeth A. O’Connor, and Johanna R. Sheer

Part 3 MAXILLOFACIAL 99

11 Unilateral and bilateral cleft lip repair 101

Rizal Lim, Catherine Gordon, and Seth R. Thaller

vii
viii Contents

12 Cleft palate repair: The Furlow double-opposing Z-plasty, the Von Langenbeck
palatoplasty, and the V-Y pushback palatoplasty 111
Jason W. Edens, Samuel Golpanian, Kriya Gishen, and Seth R. Thaller
13 Orbital floor fracture 123
Urmen Desai, William Blass, and Henry K. Kawamoto
14 Mandible fracture management 133
Larry H. Hollier Jr., Amy S. Xue, and Edward Buchanan
15 Zygomatic and zygomaticomaxillary complex (ZMC) fractures 139
David E. Morris and Mimis N. Cohen

Part 4 COSMETIC 147

16 Non-surgical facial rejuvenation with neuromodulators and dermal fillers 149

Haruko Okada and David J. Rowe
17 Upper lid blepharoplasty 159
Ari S. Hoschander and Amie J. Kraus
18 Lower eyelid blepharoplasty 165
Urmen Desai, Andrew Rivera, and Richard Ellenbogen
19 Brow lift 173
Christopher J. Salgado, Tuan Tran, Steven Schuster, and Elizabeth Yim
20 Facelift: The extended SMAS technique 181
Ari S. Hoschander and James M. Stuzin
21 Rhinoplasty 187
Tara E. Brennan, Thomas J. Walker, and Dean M. Toriumi
22 Correction of prominent ear 201
Alejandra Garcia de Mitchell and H. Steve Byrd
23 Breast augmentation 207
Elliot M. Hirsch and John Y.S. Kim
24 Mastopexy 213
Leila Harhaus and Ming-Huei Cheng
25 Abdominoplasty, panniculectomy, and belt lipectomy* 223
Ari S. Hoschander, Jun Tashiro, and Charles K. Herman
26 Brachioplasty 229
Anselm Wong, Samantha Arzillo, and Wrood Kassira
27 Medial thigh lift 233
Dennis J. Hurwitz
28 Liposuction 247
Alan Matarasso and Ryan M. Neinstein

Part 5 HAND 259

29 Carpal tunnel release: Open 261

Ali M. Soltani, Jose A. Baez, and Zubin J. Panthaki
30 Endoscopic carpal tunnel release: Anterograde single incision* 265
Ari S. Hoschander, Matthew Mendez-Zfass, and Patrick Owens
31 Open trigger finger release for stenosing tenosynovitis 271
Benjamin J. Cousins and Haaris S. Mir
32 Surgical approaches to the hand and wrist 275
Ross Wodicka and Morad Askari

* Video available on line. See chapter for link.

Foreword
How does a surgeon learn to operate? I hope the
old adage of “see one, do one, teach one” is in the
past. Substitutes for training always fall short when
measured against excellent teaching, reading,
introspective analysis, and subsequent experience.
Plastic surgery, unlike other surgical special-
ties, is more about problem solving than seeking
a specific operation. For me, applying fundamen-
tal conceptual principles similar to those champi-
oned early by Gillies and Millard1 usually pointed
toward a pleasing resolution. Operative Procedures
in Plastic, Aesthetic, and Reconstructive Surgery
provides detailed descriptions of the most com-
monly used plastic surgical procedures.
All operations follow an orderly set of moves.
Experience allows seamless deviations as unex-
pected events arise. A lesson from my mentor, Paul
L. Tessier, illustrates the merit of following a defined
path. The organizers of the 1975 International
Society of Plastic Surgery meeting in Paris asked
Tessier to perform a LeFort III operation for live
transmission. He was allotted 75 minutes to operate
on half of the face to complete the operation. Tacked
on an operating room wall was a list of approxi-
mately 275 steps needed to complete the procedure.
He completed a flawless operation with time to
spare. Recalling this story, I posted a list of steps to
help separate craniopagus twins at the University of
California at Los Angeles in 2002.
This text leads the reader through detailed,
step-by-step depictions of operations. Applicable
illustrations complement the text. In addition,
a list of the essential equipment required for the
operations is provided. Thus, the efficiency of
the entire operating staff increases, and patient
safety is enhanced. To complete the management
of the patient, postoperative instructions as well
as measures to diminish complications are pro-
vided. Finally, unfortunately demanded by today’s
health industry and not taught in any curricu-
lum, there are handy lists of the most commonly
accepted CPT codes associated with the described
procedures.
Ari Hoschander and his collaborators are to
be congratulated for crafting a refreshing, concise
guide for all levels of students of plastic surgery.
REFERENCE
1. Gillies HD, Millard DR Jr. The Principles and
Art of Plastic Surgery. 2 vols. Boston, MA:
Little, Brown; 1957.
Henry K. Kawamoto Jr., DDS, MD
Clinical Professor of Plastic and Reconstructive
Surgery, University of California Los Angeles
Medical Center, Los Angeles, California
ix
Preface
We set out to compile this book because we felt
there was a need for its content in the plastic surgery
literature. The goal was to create a list of the most
commonly performed plastic and reconstructive
procedures and then dedicate an entire chapter to
teaching the reader how to perform the operation.
We focus on the technical aspects of the operation
and deemphasize the disease process and patho-
physiology, which are covered extensively in vari-
ous other texts. We sought authors from around the
world who are considered experts in specific aspects
of plastic and reconstructive surgery to write the
chapters on topics in their specialty. We are thank-
ful that we were s­uccessful. Notice that the list of
authors includes editors of major plastic surgery
journals as well as chairs, professors, and educators
in plastic surgery departments and divisions, all
of whom dedicated their time to contribute to this
­project to further the education of the readers.
This volume provides a comprehensive, step-by-
step description of how to perform the most com-
mon plastic, aesthetic, and reconstructive surgical
procedures. The focus is on preoperative markings,
intraoperative details, avoidance of complications,
and postoperative instructions. Authors take the
reader through the operation with multiple photo-
graphs, drawings, and detailed descriptions. Each
chapter centers on a well-documented technique
for a specific clinical diagnosis.
Exactly how to perform each of the most com-
monly encountered operations is presented. Every
plastic surgeon has a handful of procedures that
he or she performs regularly and a host of other
procedures that are performed only occasion-
­
ally. This list differs from surgeon to surgeon and
locale to locale. Our goal is to provide a guide for
the p­ erformance of all of these operations to level
the  playing field. This will inevitably improve
patient safety and outcomes.
The focus here is intraoperative detail. Authors
assume readers already have an understanding of
specific indications to perform the procedure and
of the underlying pathophysiology of the disease.
The chapters provide detailed explanations and
descriptions of the techniques involved in the suc-
cessful performance of the operations. Individual
chapters provide a table delineating the equipment
necessary to complete the procedure. The book
may be used as a preoperative guide for operating
room staff, improving their ability and efficiency
to have the patient and room ready in a timely
fashion. Also, the most commonly accepted CPT
(Current Procedural Terminology) codes are avail-
able for the operations described.
This book will be an asset to any practicing plas-
tic surgeon, fellow or resident in plastic surgery, as
well as residents from surgical subspecialties who
rotate through plastic surgery services. My coeditors
and I thoroughly enjoyed compiling and contribut-
ing to it, and we hope this will be an educational
source of material for the future of plastic, aesthetic,
and reconstructive surgery.
Ari S. Hoschander, MD
xi
Editors
Ari S. Hoschander, MD
Division of Plastic, Aesthetic and Reconstructive
Surgery, the DeWitt Daughtry Family
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Christopher J. Salgado, MD, FACS
Department of Plastic, Aesthetic and
Reconstructive Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Wrood Kassira, MD, FACS
Division of Plastic, Aesthetic and Reconstructive
Surgery, the DeWitt Daughtry Family
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Seth R. Thaller, MD, DMD, FACS
Division of Plastic Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
xiii
Contributors
Samantha Arzillo
University of Miami, Miller School of Medicine,
Miami, Florida
Morad Askari
Division of Plastic & Reconstructive Surgery,
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida;
Division of Hand & Upper Extremity Surgery,
Department of Orthopedics, University of Miami,
Miller School of Medicine, Miami, Florida
Jose A. Baez
Atlanta Hand Specialists
Smyrna, Georga
Devra B. Becker
Case Western Reserve University Hospitals/Case
Medical Center and the Louis Stokes VA Medical
Center, Lyndhurst, Ohio
Kristin J. Blanchet
Comprehensive Foot & Ankle Surgery, Jupiter,
Florida
William Blass
Department of General Surgery,
University of Miami/Jackson Memorial Hospital,
Miami, Florida
Tara E. Brennan
Department of Otolaryngology-Head and Neck
Surgery, University of Illinois College of Medicine
at Chicago, Chicago, Illinois
Edward Buchanan
Division of Plastic Surgery, Baylor College
of Medicine, Houston, Texas
H. Steve Byrd
Department of Plastic Surgery, University of
Texas Southwestern Medical Center at Dallas,
Dallas, Texas
Ming-Huei Cheng
Division of Microsurgery, Department of Plastic
and Reconstructive Surgery, Chang Gung
Memorial Hospital, Chang Gung University
College of Medicine, Taoyuan, Taiwan
Harvey Chim
Department of Plastic Surgery, Case Western
Reserve University, Cleveland, Ohio
Mimis N. Cohen
Division of Plastic, Reconstructive, and Cosmetic
Surgery, University of Illinois at Chicago,
Chicago, Illinois
Benjamin J. Cousins
South Florida Hand Surgery, Miami Beach,
Florida
Urmen Desai
Desai Plastic Surgery of Beverly Hills,
Beverly Hills, California
Jason W. Edens
Division of Plastic Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Richard Ellenbogen
Beverly Hills Body, Beverly Hills, California
Karen Kim Evans
Department of Plastic Surgery, Georgetown
University Medical Center, Division of Wound
Healing, Washington, DC
Shaili Gal
Department of Plastic and Reconstructive
Surgery, UC Davis Medical Center, Sacramento,
California
Alejandra Garcia de Mitchell
Department of Surgery, Division of Plastic
Surgery, University of Texas Health Science
Center at San Antonio, San Antonio, Texas
xv
xvi Contributors
Kriya Gishen
Division of Plastic Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Samuel Golpanian
Department of General Surgery, University of
Miami/Jackson Memorial Hospital, Miami, Florida
Catherine Gordon
University of Miami, Miller School of Medicine,
Miami, Florida
Dennis C. Hammond
Department of Surgery, Michigan State
University College of Human Medicine,
East Lansing, Michigan;
Plastic and Reconstructive Surgery, Grand Rapids
Medical Education and Research Center for
Health Professions, Grand Rapids, Michigan
Leila Harhaus
Department of Hand, Plastic and Reconstructive
Surgery, Burn Care Unit, University of
Heidelberg, BG Trauma Center Ludwigshafen,
Ludwigshafen, Germany
Charles K. Herman
Division of Plastic and Reconstructive Surgery,
Pocono Health Systems/Pocono Medical
Center, East Stroudsburg, Pennsylvania;
Department of Surgery, The Commonwealth
Medical College, Scranton Pennsylvania;
Division of Plastic and Reconstructive Surgery,
Albert Einstein College of Medicine New York,
New York
Elliot M. Hirsch
Division of Plastic Surgery, Northwestern
University, Chicago, Illinois
Larry H. Hollier Jr.
Division of Plastic Surgery, Baylor College
of Medicine, Houston, Texas
Elan Horesh (Illustrations)
University of Miami, Miller School of Medicine,
Miami, Florida
Ari S. Hoschander
Division of Plastic, Aesthetic and Reconstructive
Surgery, The DeWitt Daughtry Family
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Dennis J. Hurwitz
Department of Plastic Surgery, University of
Pittsburgh; Hurwitz Center for Plastic Surgery,
Pittsburgh, Pennsylvania
Tarik M. Husain
MOSA Plastic/Aesthetic Surgery, Miami, Florida
University of Miami Plastic Surgery,
Miami, Florida;
OrthoNOW Orthopaedic/Hand Surgery,
Doral, Florida
Wrood Kassira
Division of Plastic, Aesthetic and Reconstructive
Surgery, The DeWitt Daughtry Family
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Henry K. Kawamoto
University of California Los Angeles Medical
Center, Los Angeles, California
John Y.S. Kim
Division of Plastic Surgery, Northwestern
University, Chicago, Illinois
Amie J. Kraus
Department of Surgery, Hofstra
University North Shore-Long Island Jewish
Health System, Manhasset, New York
Rizal Lim
Division of Plastic Surgery, University of Miami,
Miami Florida
Samir Mardini
Division of Plastic Surgery, Mayo Clinic,
Rochester, Minnesota
Alan Matarasso
Department of Plastic Surgery, Manhattan Eye,
Ear & Throat Hospital/Lenox Hill Hospital/North
Shore-Long Island Jewish Health System,
New York, New York
Matthew Mendez-Zfass
Department of Orthopaedics, University
of Miami, Miller School of Medicine, Miami,
Florida
Haaris S. Mir
Joseph M. Still Burn Center, Burn
and Reconstructive Centers of Florida,
Miami, Florida
David E. Morris
Division of Plastic, Reconstructive, and Cosmetic
Surgery, University of Illinois at Chicago,
Chicago, Illinois
Maurice Y. Nahabedian
Department of Plastic Surgery, Georgetown
University Hospital, Washington, DC

Ryan M. Neinstein
Department of Plastic Surgery, Manhattan Eye,
Ear and Throat Hospital/Lenox Hill Hospital/
North Shore-Long Island Jewish Health System,
New York, New York
Elizabeth A. O’Connor
BayCare Clinic Plastic Surgery, Green Bay,
Wisconsin
John Oeltjen
Division of Plastic, Aesthetic and Reconstructive
Surgery, The DeWitt Daughtry Family
Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Michael P. Ogilvie
Division of Plastic, Maxillofacial and Oral Surgery,
Duke University Medical Center, Durham,
North Carolina
Haruko Okada
Department of Plastic Surgery, Case Western
Reserve University, Cleveland, Ohio
Dennis P. Orgill
Department of Surgery, Division of Plastic
Surgery, Harvard Medical School, Brigham and
Women’s Hospital, Boston, Massachusetts
Patrick Owens
Division of Hand Surgery, Department of
Orthopaedics, University of Miami, Miller
School of Medicine, Miami, Florida
Zubin J. Panthaki
Division of Plastic Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Ketan M. Patel
Department of Plastic Surgery, Georgetown
University Hospital, Washington, DC
Giorgio Pietramaggiori
Department of Plastic, Reconstructive and
Aesthetic Surgery, University Hospitals of
Lausanne, Switzerland
Andrew Rivera
University of Miami, Miller School of Medicine,
Miami, Florida
David J. Rowe
Department of Plastic Surgery, Case Western
Reserve University, Cleveland, Ohio
Christopher J. Salgado
Department of Plastic, Aesthetic and
Reconstructive Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Contributors xvii
Saja S. Scherer-Pietramaggiori
Department of Plastic, Reconstructive and
Aesthetic Surgery, University Hospitals of
Lausanne, Switzerland
Steven Schuster
Department of Plastic, Aesthetic and
Reconstructive Surgery, University
of Miami, Miller School of Medicine,
Miami Florida
Johanna R. Sheer
Grand Rapids Medical Education Program,
Michigan State University, Grand Rapids,
Michigan
Varsha R. Sinha
University of Miami, Miller School of Medicine,
Miami, Florida
Jeremy C. Sinkin
Georgetown University Hospital, Department
of Plastic Surgery, Washington, DC
Ali M. Soltani
Department of Plastic Surgery, Kaiser
Permanente Orange County, Irvine, California
James M. Stuzin
University of Miami, Miller School of Medicine,
Miami, Florida
Jun Tashiro
The DeWitt Daughtry Family Department
of Surgery, University of Miami, Miller School
of Medicine, Miami, Florida
Ryan Ter Louw
Department of Plastic Surgery, Georgetown
University Medical Center, Washington, DC
Seth R. Thaller
Division of Plastic Surgery, University of Miami,
Miller School of Medicine, Miami, Florida
Dean M. Toriumi
Department of Otolaryngology-Head and
Neck Surgery, University of Illinois College of
Medicine at Chicago, Chicago, Illinois
Tuan Tran
Department of Plastic, Aesthetic and
Reconstructive Surgery, University
of Miami, Miller School of Medicine,
Miami, Florida
Thomas J. Walker
Department of Otolaryngology-Head and
Neck Surgery, University of Illinois College
of Medicine at Chicago, Chicago, Illinois
xviii Contributors

Ross Wodicka Amy S. Xue

University of Miami, Miller School of Medicine,
Miami, Florida
Anselm Wong
Division of Plastic and Reconstructive Surgery,
University of Miami, Miller School of Medicine,
Miami, Florida
Division of Plastic Surgery, Baylor College
of Medicine, Houston, Texas
Elizabeth Yim
University of Miami, Miller School of Medicine,
Miami, Florida
 Part     1
General Reconstruction

1 Skin grafting and dermal substitute placement 03

Giorgio Pietramaggiori, Saja S. Scherer-Pietramaggiori, and Dennis P. Orgill
2 Component separation 09
Harvey Chim, Karen Kim Evans, and Samir Mardini
3 Lower extremity reconstruction 17
Jeremy C. Sinkin, Christopher J. Salgado, Karen Kim Evans, Varsha R. Sinha, and
Kristin J. Blanchet
4 Chest wall reconstruction with pectoralis major muscle flaps 37
Ryan Ter Louw and Karen Kim Evans
 1
Skin grafting and dermal substitute
placement

GIORGIO PIETRAMAGGIORI, SAJA S. SCHERER-PIETRAMAGGIORI,

AND DENNIS P. ORGILL

Introduction 4 Postoperative details 6

Preoperative markings 4 Recipient site 6
Intraoperative details 4 Donor site 6
Partial-thickness skin donor site 4 Notes 6
Full-thickness skin donor site 5 CPT coding 7
Application of the skin graft 6 References 7

INDICATIONS

1. Partial-thickness skin graft: loss of skin polytetrafluoroethylene) exposure in aesthetic

coverage without tendon, nerve, bone, or
synthetic material (i.e., silicone, titanium,
polytetrafluoroethylene) exposure
2. Full-thickness skin graft: loss of skin
coverage without tendon, nerve, bone, or
synthetic material (i.e., silicone, titanium,
or functional areas (i.e., face, hand)
3. Partial-thickness skin graft plus dermal
substitute graft: loss of skin coverage eventually
with limited tendon, nerve, or bone exposure;
loss of extensive skin area; loss of full-thickness
skin in aesthetic or functionally important areas

Table 1.1  Special equipment

Powered dermatome (e.g., Wagner [electric], Zimmer [compressed air]
dermatome [standard], Weck dermatome [for small grafts, i.e., <5 cm2]
Skin mesher (with or without a plastic carrier template)
Lubricating material (mineral oil or water-soluble gel)
Adrenaline (1 mg/mL, dilution in 1000 mL NaCl 0.9%)
Skin stapler or sutures
Donor site dressing material (petroleum-impregnated interface, gauze, bandages)
Recipient site dressing material (petroleum-impregnated interface, gauze,
bandages, or non-adherent dressing)

3
4  Skin grafting and dermal substitute placement

Table 1.2  Optional equipment Partial-thickness skin donor site

Fibrin glue
1. Infiltration of the designated area with adrena-
Integra™
line solution to reduce bleeding (Figure 1.1).
MatriDerm®
2. A lubricating material (water-soluble gel or
Sub-atmospheric pressure device mineral oil) is applied on the donor site and
Non-adherent dressing on the dermatome to improve gliding.
3. The surgeon passes the dermatome (usually
set at 0.2 mm or 0.0012 to 0.0014 in.) with
INTRODUCTION a 45° angle and constant pressure and speed
with a fixed pressure (Figure 1.2a; a manual
Skin grafting is one of the most frequently per- ­dermatome is shown).
formed interventions in plastic surgery. This 4. Small slits can be made in the graft using
review is based on previous reviews but with a meshing machine (Figure 1.2b). This allows
more emphasis on surgical technique.1,2 Tables 1.1 for expansion of the size of the graft as
and 1.2 provide lists of the s­ pecialized and optional well as holes for egress of blood and serum
equipment, respectively. As a  relatively simple (Figure 1.2c). The expansion size can be v­ aried
procedure, skin grafting provides rapid and reli-
able skin coverage. Skin grafting is defined as skin
transfer from a healthy donor site to cover skin loss
at the recipient site. As the avascularized tissue is
freely transferred, the skin graft take (successful
union) largely depends on rapid revasculariza-
tion. The ­recipient site should be clear of necrotic,
infective, or avascular ­elements to maximize skin
graft take. When materials such as blood, serum,
or purulent ­discharge exist at the interface, revas-
cularization of the graft is inhibited. High levels
of bacteria in the wound result in infection and
Wheals at the edge
loss of the graft. The t­hickness of dermis in the of the graft area
graft ­influences the quality of the grafted skin.
Thicker dermis results in higher primary con-
traction (contraction of the detached graft), takes
longer to engraft, and counters secondary wound
contraction. Full-thickness skin grafts result in
­
an excellent ­aesthetic and ­functional result; split-
thickness skin grafts often result in a less aesthetic
and less functional o ­utcome. In contrast, thin
skin grafts rapidly revascularize but often provide
unstable coverage and can undergo ­ significant
­secondary contraction. Area of graft infiltrated
through wheals

PREOPERATIVE MARKINGS Figure 1.1  Donor site preparation. Bleeding

The skin graft donor site should be marked to best
match the size of the recipient site.
INTRAOPERATIVE DETAILS
Disinfect donor and recipient sites with antiseptic
skin preparation (e.g. povidone-iodine).
is one of the complications most currently
­encountered at the donor site. Subcutaneous
infiltration with diluted epinephrine (tumes-
cent technique) s­ ignificantly reduces blood
loss. (From Scherer SS, Pietramaggiori GP,
Orgill DP. Skin graft. In Gurthner GC, Neligan
PC, eds. Principles. New York, NY: Elsevier;
2012:319–338. Plastic Surgery, Vol. 1. With
permission.)
 Intraoperative details  5

Figure 1.2  Split-thickness skin graft harvesting and grafting. (a) Split-thickness skin graft harvested
with manual or electrically driven dermatome. (b) The skin graft is positioned flat on the mesh
template with the dermal site facing upward. (c) The skin graft can be expanded up to six times
the original size with a skin mesher or with a sharp knife. (d) The split-thickness skin graft is fixed on
the recipient wound bed by sutures, surgical staples, or fibrin glue. (From Scherer SS, Pietramaggiori
GP, Orgill DP. Skin graft. In Gurthner GC, Neligan PC, eds. Principles. New York, NY: Elsevier;
2012:319–338. Plastic Surgery, Vol. 1. With permission.)

from 1:1 to 6:1 (1.5:1 is commonly used).
The graft is kept moist using normal saline.
5. The donor site can be covered with a variety of
dressing materials depending on the surgeon’s
preference.
6. The skin graft is affixed with sutures, staples, or
fibrin glue (Figure 1.2d). A compressive dress-
ing is applied to prevent shear between the
graft and recipient site.
Full-thickness skin donor site
The full-thickness skin donor site is usually ellip-
tical and in the inguinal, lower abdominal fold;
elbow fold; or retro-auricular, superior eyelid, or
upper eyebrow region:
1. Infiltration with local anesthetic with dilute
epinephrine solution
6  Skin grafting and dermal substitute placement
2. Sharp dissection of the skin with the entire
dermis using a large scalpel blade
3. Complete defatting of the dermal site with
­scissors (Reynolds or face-lift)
4. Manual perforation of the graft with a pointed
scalpel blade to allow for fluid drainage
5. Careful hemostasis of donor site
6. Sharp liberation of donor site wound margins
if necessary
7. Direct closure
8. Simple wound dressing
Application of the skin graft
1. After careful wound bed preparation and
hemostasis, the graft is placed on the raw
recipient site area.
2. The graft can be preferably fixed by sutures
or surgical staples in full-thickness skin
grafts. Fibrin glue is especially useful in
large ­split-thickness grafts that cover uneven
surfaces.
3. If additional stabilization is required (as for
full-thickness skin grafts) or early mobilization
is a goal (i.e., joint wounds), two options can be
considered:
a. Bolster dressing: The graft is sutured in
place, and the ends of the sutures are
left intentionally long. A non-adherent
layer (i.e., petroleum-impregnated gauze)
is placed on the graft and covered with
­bolstered cotton or gauze. Sutures are
secured across the second layer to maintain
fixed pressure on the wound site.
b. Sub-atmospheric pressure ­dressing
­wound-healing device: A n ­ on-adherent
dressing is placed on the graft
(i.e., ­petroleum-impregnated gauze
or a s­ ilicone sheet) under the wound
bed i­ nterface. The vacuum should
be set between 50 and 125 mmHg.
­Sub-atmospheric pressure dressings are
­especially useful to fix large skin grafts
onto uneven surfaces.
Integra (Integra LifeSciences, Plainsboro,  NJ)
and MatriDerm (MedSkin Solutions, Billerbeck,
Germany) are commonly used to augment
the d­ermal layer. Both dermal substitutes are
available in different thicknesses. Thin dermal
­ Dermal substitutes can be grafted over small
substitutes allow simultaneous skin grafting
­ areas of exposed bone or tendon. In this case, it is
(­one-step  ­
procedure); thick dermal layers need
to be ­revascularized, usually over 2–3 weeks,
followed by a thin ­
­ split-thickness skin graft
­(two-step procedure).
POSTOPERATIVE DETAILS
Recipient site
1. The skin graft should be left in a fixed
­position (as much as possible) for at least 3 to
5 days. Shearing forces cause partial/total
graft loss.
2. The bolster or compressive dressing is usually
removed between 5 and 7 days after grafting.
3. Following the first evaluation, a d
­ ressing
­composed of petroleum-impregnated gauze
can be used. Regular dressing changes should
be continued until complete reepithelialization.
Donor site
1. If a semi-permeable polyurethane dressing
has been used, serum accumulation should be
periodically evacuated via a drain or a syringe.
2. If a petroleum-impregnated gauze has
been used, it can be allowed to dry and
­spontaneously come off (generally in 14 to
21 days).
NOTES
Optimal donor sites for facial wounds are above
the clavicle for best color match. Ideal donor sites
are adjacent to the wound bed for texture and
color.
The donor site of split-thickness skin grafts
heals by reepithelialization over 2–3 weeks and
leaves a scar, the visibility of which is dependent
on patient factors as well as the thickness of der-
mis that was removed. Non-exposed areas are
usually selected as donor sites (i.e., thigh, trunk,
and buttocks).
If the graft is too large for the recipient site, it is
possible to re-place the graft onto the donor site,
but the cosmetic results are poor (patchwork-like).
It should be noted that a skin graft can be pre-
served on moist gauze at 4°C for up to 2 weeks and
then successfully grafted.

recommended to prepare the cortical bone with
several holes by drilling to induce more efficient
vascularization and cell engraftment in the dermal
template. In the skull, burring down to the diploic
space is effective.
CPT CODING
15002–15005 Initial wound preparation of
­recipient site (burn and wound p ­ reparation or
incisional or excisional release of scar con-
tracture resulting in an open wound requiring
a skin graft)
References 7
15100–15261 Autologous skin grafts
(e.g., split-thickness skin graft, full-thickness
skin graft, epidermal graft)
REFERENCES
1. Orgill DP. Excision and skin g
­ rafting
of thermal burns. N Engl J Med.
2009;360(9):893–901.
2. Scherer SS, Pietramaggiori GP, Orgill DP.
Skin graft. In Gurthner GC, Neligan PC, eds.
Principles. New York, NY: Elsevier;
2012:319–338. Plastic Surgery, Vol. 1.
 2
Component separation

HARVEY CHIM, KAREN KIM EVANS, AND SAMIR MARDINI

Introduction 9 Postoperative details 13

Preoperative markings 11 Notes 13
Intraoperative details 11 CPT coding 15
Technique modification: Component Suggested Readings 15
separation with preservation of perforators 13

INDICATIONS

1. Large ventral hernias that cannot be closed 2. Large abdominal wall defects after extirpative
primarily by apposition of the anterior rectus surgery or flap harvest that cannot be closed
sheath primarily by apposition of the anterior rectus
sheath

Table 2.1  Special equipment

Warm saline bath not to exceed 37°C
Cefoxitin 2 g IV given prior to incision
Jackson-Pratt #10 flat drains, 2 per side
Sterile antiseptic skin preparation
Choice of synthetic versus biologic mesh

INTRODUCTION myocutaneous (VRAM) flap. Key to successful

Large abdominal hernias pose a reconstructive
challenge. Component separation provides a means
of recruiting innervated, vascularized autologous
tissue for closure of ventral hernias or for immedi-
ate closure of large abdominal wall defects result-
ing from resection of the midline r­ ectus abdominis
complex or harvest of a vertical rectus abdominis
surgery is thorough ­understanding of the anatomy
of the anterior abdominal wall. Release of the
external oblique muscles and the posterior rectus
sheath allows the paired rectus abdominis muscles
to come together in the midline to form a dynamic
muscular sling (Figure 2.1). Special equipment for
the procedure is shown in Table 2.1.

9
10  Component separation

(a)   (b)

(c)

Figure 2.1  Cadaver dissection. (a) The rectus abdominis muscle, inferior margin of the ribs, anterior
superior iliac spine, inguinal ligament, and external oblique muscles are marked. (b) Skin and sub-
cutaneous tissue elevated off the abdominal wall fascia; an incision is made in the external oblique
fascia lateral to the semilunar line, and the external oblique is separated from the internal oblique
laterally to the midaxillary line. (c) Posterior rectus sheath release 2 cm lateral to the medial edge of
the rectus muscle.  (Continued)

(d)
Figure 2.1 (Continued)  Cadaver dissection. (d) Posterior rectus sheath dissected free from the rectus
muscle.
PREOPERATIVE MARKINGS
1. Lateral border of rectus abdominis muscle
(semilunaris line)
2. Anterior superior iliac spine
3. Inguinal ligament
4. Inferior margin of the ribs
5. External oblique muscles
INTRAOPERATIVE DETAILS
1. Incision is made on the margin of the skin
graft or scar tissue overlying the ventral
­hernia (Figure 2.1a and b).
2. Sharp dissection laterally is used to under-
mine the skin and subcutaneous tissue over
the abdominal wall (anterior rectus sheath
medially, then external oblique laterally). Care
is taken to prevent inadvertent enterotomies.
3. If a skin graft overlies the hernia, it is removed
with a #10 blade. If the surgeon is not confi-
dent that closure of the hernia is possible, the
skin graft is left in place until it is clear that
closure is possible. Care is taken not to injure
the underlying intestine. If an enterotomy
is made, it must be recognized and closed.
Copious irrigation is performed. In the case
of an enterotomy, we avoid use of prosthetic
mesh; biologic mesh can be used.
4. The dissection is carried laterally up to 6 to
10 cm lateral to the semilunar line.
Intraoperative details  11
5. The semilunar line is identified and marked.
A longitudinal line is marked 2 cm lateral to the
semilunar line running 5 to 10 cm above and 5
to 10 cm below the level of the hernia. An inci-
sion is made through the external oblique
fascia. The external oblique is separated from
the internal oblique muscle and fascia medially
to laterally to the midaxillary line.
6. For hernias that extend close to the xiphoid,
advancement of the rectus muscles m ­ edially
can be a challenge. In these cases, the inci-
sion through the external oblique is extended
above the ribs and then goes in an oblique
fashion across the anterior rectus sheath. The
rectus muscle is undermined over the ribs and
advanced medially (see Figure 2.2a and b). Care
is taken to identify the deep s­ uperior epigastric
vessels so they are not injured during dissection.
7. Release of the external obliques bilaterally
allows advancement of approximately 3 to
5 cm in the upper third of the abdominal wall,
7 to 10 cm in the middle third, and 3 cm in
the lower third.
8. Adequacy of release and residual tension are
assessed by pulling the paired rectus abdomi-
nis muscles to the midline.
9. Excess skin and scar overlying the ventral
hernia are excised.
10. Another component of the release involves
a longitudinal cut in the posterior rectus
sheath (Figure 2.1c and d). Intestinal tissue
12  Component separation

(a)

(b)

Figure 2.2  (a) Release of the external oblique muscle is completed bilaterally, and the midline is
closed. (b) To move the upper rectus muscles medially, the external oblique fascia is released over the
level of the ribs, and the superior aspects of the muscles are mobilized and moved medially (different
patient than in Figure 2.2a).

and adhesions are released from the posterior
rectus sheath all the way lateral to the lateral
margin of the rectus muscles. Going further
laterally is beneficial in most circumstances
to be able to secure a piece of mesh if that is
to be used. A line is marked on the poste-
rior rectus sheath 2 cm lateral to the medial
margin of the rectus muscle. An incision
is made in the posterior rectus sheath. The
posterior rectus sheath is then separated from
the rectus muscles medially to laterally to
the lateral margin of the rectus muscle. This
allows further advancement of approximately
2 cm in the upper third of the abdominal wall,
2 to 4 cm in the ­middle third, and 2 cm in the
lower third.
1 1. The intraperitoneal cavity is irrigated with
warm saline prior to closure.
12. The midline structures (medial edge of the
rectus fascia) are brought together using
running #1 PDS® sutures (polydioxanone,
Ethicon, Norderstedt, Germany).
13. If the posterior rectus sheath can be approxi-
mated, then a prosthetic or biologic mesh is
placed in the retrorectus space followed by
approximation of the rectus muscles.
14. If the posterior rectus sheath cannot be
approximated, a large piece of prosthetic or
biologic mesh is placed in the abdominal cav-
ity as an underlay spanning the abdominal
wall from the anterior axillary line on one
side to the anterior axillary line on the other
side and from the inferior rib margin cepha-
lad to the iliac spine caudad.
15. If the anterior rectus sheath and rectus
muscles will not come together in the

­ idline, a biologic or prosthetic mesh is
m abdominus muscles. The incision is made on the
placed as an underlay to the abdominal wall.
Another piece of mesh can be used as an
inlay or overlay as well to support the repair.
This is anchored to the anterior rectus fascia
with multiple horizontal mattress sutures
using #1 PDS suture. If biologic mesh is used,
Strattice™ (LifeCell™, Branchburg, NJ) is
preferred to AlloDerm® (LifeCell) as it has
a decreased capacity to stretch. Synthetic
mesh should be avoided if the surgical
site is c­ ontaminated and in patients with
­comorbidities that cause an unacceptably high
risk for ­developing surgical site i­ nfection.
Often, f­ ollowing anchoring of the underlay,
the anterior rectus sheath can be closed in the
midline due to r­ edistribution of tension.
16. The anterior rectus sheath is then apposed
using multiple #1 or 0 PDS sutures placed in a
vertical or figure-of-eight mattress fashion.
17. Two #10 flat Jackson-Pratt (JP) drains are placed
on each side to drain the subcutaneous pocket.
1 8. The skin is closed in layers.
19. A petroleum-based ointment is placed over
the incisions, followed by a dressing. An
abdominal binder is applied for support, par-
ticularly when the patient is ambulating or
coughing. In patients with a large pannus, we
will use a Steri-Drape ™ (3M™, St. Paul, MN)
placed from one side of the abdominal wall
to the other while taking tension off the mid-
line incision. One person will come from the
lower end and use both hands to bring the
pannus together from one side of the patient
to the other. The Steri-Drape is placed on the
abdominal wall while the pannus is squeezed
in the midline. This allows for the tension to
be on the Steri-Drape instead of the midline
incision. Multiple layers of Steri-Drape can
be placed. This is removed in 2 to 3 days.
Maceration of the skin does occur with this
type of dressing.
TECHNIQUE MODIFICATION:
COMPONENT SEPARATION WITH
PRESERVATION OF PERFORATORS
All steps for component separation with pres-
ervation of the perforators are similar to those
outlined except during the elevation of the
skin and subcutaneous tissues over the rectus
Notes 13
margin of the skin graft or scar tissue overly-
ing the ventral hernia. Sharp dissection laterally
is used to undermine the skin and subcutane-
ous tissue over the abdominal wall (anterior
rectus sheath medially, then external oblique
laterally). Perforators supplying the overlying
subcutaneous tissues are identified and preserved
(Figure 2.3). Clusters of perforators are easier to
preserve. A cuff of t­ issue around the perforators
should be preserved to prevent inadvertent dam-
age to the  ­perforators by retraction on the skin
flaps. There is no exact number of perforators
that should be p ­ reserved—the more the better.
However, a key element is the size and pulsatil-
ity of a p
­ erforator. Larger ones have better supply
to tissues. Venous  drainage through perforators
could be a ­critical factor in survival of skin flaps
and therefore should be preserved and not dam-
aged during dissection and retraction. Most of
the perforators that are preserved traverse the
rectus ­abdominus muscles. Lateral to the semi-
lunar line, the skin and subcutaneous tissue are
separated from the external oblique muscles.
This is required for making the incision through
the external oblique fascia. Once the incision is
made, follow steps 6 through 19 above.
POSTOPERATIVE DETAILS
Drains are kept in until output is <30 to 40 cc
per drain over a 24-hour period. In some cases,
drains may stay in as long as 4 weeks. Patients
are instructed to wear the abdominal binder at all
times for 6 weeks and should not engage in any
moderate-to-heavy lifting for at least 6 weeks. The
abdominal binder can produce compression that
hinders blood supply; therefore it should not be
placed tightly.
NOTES
Patients should be advised to avoid any heavy lift-
ing if possible for the rest of their life and should
not perform heavy weight-lifting or sit-ups. Other
authors practice endoscopic or minimally inva-
sive component separation aimed at decreasing
the amount of undermining to reach the lateral
edge of the rectus abdominis muscles. Each is a
viable option and can be technically challeng-
ing alternatives to open component separation,
14  Component separation

(a)

(b)

(c)

Figure 2.3  Preservation of perforators: (a) The skin and subcutaneous tissue are elevated medially to
laterally over the anterior rectus sheath and over the external oblique fascia and muscle. Perforators
preserve blood supply yet allow access to release the external oblique fascia. (b) An incision is
made in the rectus fascia. (c) The external oblique fascia is elevated from the internal oblique while
­preserving perforators.

with the advantage of preserving most perforators
­supplying the midline abdominal skin and reduc-
ing the incidence of wound-healing complications.
CPT CODING
49565 Herniorrhaphy, recurrent, reducible
43566 Herniorrhaphy, recurrent, incarcerated
13101-51 Complex repair, trunk; first 7.5 cm
13102 Complex repair, trunk; additional 5 cm
15734 Muscle flap of the trunk (component
separation)
15777 Implantation of biologic implant (list
separately in addition to code for primary
procedure)
49568 Implantation of mesh or other prosthesis
for open incisional or ventral hernia repair or
mesh for closure of debridement for necrotiz-
ing soft tissue infection (list in addition to code
for the incisional or ventral hernia)
Repair of a recurrent, incarcerated hernia using
component separation and release of the poste-
rior rectus sheaths bilaterally (20 cm each side)
would be coded as 43566, 13101-51, 13102 × 3,
15734 × 2 (one code for each side). If Strattice
was used as well to reinforce the closure, then
15777 would be added to the CPT coding.
Suggested readings  15
SUGGESTED READINGS
Buck DW 2nd, Khalifeh M, Redett RJ. Plastic
surgery repair of abdominal wall and
pelvic floor defects. Urol Oncol. 2007
Mar–Apr;25(2):160–4.
Halvorson EG. On the origins of c­ omponents
separation. Plast Reconstr Surg. 2009
Nov;124(5):1545–9. doi: 10.1097/
PRS.0b013e3181b98ab8.
Mathes SJ, Steinwald PM, Foster RD,
Hoffman WY, Anthony JP. Complex
­abdominal wall reconstruction: a comparison
of flap and mesh closure. Ann Surg. 2000
Oct;232(4):586–96.
Ramirez OM, Ruas E, Dellon AL. “Components
separation” method for closure of
­abdominal-wall defects: an anatomic
and clinical study. Plast Reconstr Surg.
1990 Sep;86(3):519–26.
Shestak KC, Edington HJ, Johnson RR. The
­separation of anatomic components tech-
nique for the reconstruction of massive
midline abdominal wall defects: anatomy,
surgical t­ echnique, applications, and limita-
tions ­revisited. Plast Reconstr Surg. 2000
Feb;105(2):731–8; quiz 739.

Lower extremity reconstruction
JEREMY C. SINKIN, CHRISTOPHER J. SALGADO, KAREN KIM EVANS,
VARSHA R. SINHA, AND KRISTIN J. BLANCHET
Introduction 18
Diabetic foot wound reconstruction 19
Preoperative markings 19
Intraoperative details of debridement 19
Postoperative details 20
Forefoot plantar ulcers: Achilles
lengthening, fillet of toe flaps 20
Preoperative markings 20
Intraoperative details of percutaneous
tendo-Achilles lengthening 20
Intraoperative details of gastrocnemius
recession 21
Postoperative details 21
Intraoperative details of a toe fillet flap 21
Postoperative details 21
Midfoot plantar ulcers: Primary closure, skin
grafting, local flaps 22
Intraoperative details of primary closure (rare) 22
Intraoperative details of split-thickness skin
grafting 22
Intraoperative details of the V-Y
advancement flap 23
Postoperative details 23
Intraoperative details of random pattern
rotation plantar foot flaps 23
Postoperative details of a random pattern
rotation plantar foot flap 24
Hindfoot plantar ulcers: abductor hallucis,
abductor digiti minimi, flexor digitorum
brevis, calcenectomy, medial plantar
artery flaps 24
3
Intraoperative details of the medial plantar
artery flap 24
Notes 25
Skin substitutes 25
Intraoperative details of Integra Bilayer
Matrix wound dressing application 26
Postoperative details 26
Traumatic lower extremity wound
reconstruction 26
Timing of lower extremity trauma 26
Intramedullary nail versus external fixation 27
Fasciotomies for compartment syndrome of
the lower leg 27
Knee and upper third of leg coverage:
Medial or lateral gastrocnemius flap 27
Middle third of lower extremity defect:
Soleus flap 29
Free-flap reconstruction of lower extremity
wounds 30
Rectus abdominis free flap 30
Gracilis muscle free flap 31
Latissimus dorsi free flap 33
Anterolateral thigh flap 34
CPT coding 35
Suggested readings 36
17
18  Lower extremity reconstruction
INDICATIONS
1. Contaminated or infected ulcer in a diabetic
patient
2. An acute or subacute trauma to the lower
extremity resulting in soft tissue defect with or
without underlying fractures
Table 3.1  Special equipment
Pneumatic extremity tourniquet and padding
Handheld Doppler and sterile Doppler probes
Two sterile setups (one for pre- and one for post
debridement) and instrument trays
Culture swabs (two sets – pre- and post
debridement)
Methylene blue and hydrogen peroxide
Curettes (pre debridement)
Rongeurs (pre debridement)
Osteotomes (pre debridement)
(Versajet™ hydrosurgery system)
Pulse lavage and 3 liters of normal saline
Optional Products (Integra, Apligraf)
Dermatome and mesher and mineral oil for split
thickness skin graft
Negative pressure wound therapy machine
Dressings
Plaster splint material
Compression dressings
Offloading shoewear
INTRODUCTION
Plastic surgeons often help reconstruct or salvage
lower extremities that have been severely trau-
matized, whether by chronic disease processes
or by an acute injury. The goal of lower extrem-
ity reconstruction is to heal the soft tissues over
vital structures, such as bone, nerve, tendon, and
vessel and to provide a durable, pain-free, and
functional limb for ambulation. The focus of this
chapter is diabetic and traumatic lower extremity
reconstruction.
Diabetic foot wounds are troublesome for the
patient and care provider alike. Diabetic patients are
prone to developing foot wounds secondary to neu-
ropathy and loss of protective senses, b
­ iomechanical
3. Other lower extremity wound etiologies, such
as autoimmune, venous stasis, or ischemic
causes or following tumor resection
abnormalities, and tissue ischemia. The most com-
mon location for diabetics to develop foot ulcers is the
plantar forefoot. Foot ulcers tend to be chronic and
recurrent and may go unnoticed by affected individ-
uals until the wounds are large or infected. Diabetic
foot wounds are associated with increased risk for
limb loss. Regular surveillance and primary preven-
tion of foot ulcers in diabetic patients is vital; however,
when wounds develop, early and aggressive therapy
should be initiated. Thorough vascular examina-
tion with handheld Doppler and noninvasive testing
should be done prior to any reconstruction. Vascular
surgery should be consulted for input regarding the
need for bypass or endovascular surgery. Closure is
usually delayed up to 2 weeks after bypass to ensure
adequate blood supply prior to reconstruction.
With thorough knowledge of wound pathophysi-
ology, familiarity with topical agents, and expertise
in surgical reconstruction, the plastic surgeon is
uniquely qualified to assess healing potential and
provide surgical debridement and staged closure
of diabetic foot ulcers. Numerous techniques are
available for the plastic surgeon to close diabetic
foot wounds. The reconstructive procedure chosen
should be the simplest indicated for each particu-
lar wound location and characteristic. Paramount
to successful treatment of diabetic foot ulcers is a
thorough initial neurovascular and biomechanical
examination. Infected wounds should be debrided
of all nonviable tissue and culture-directed anti­
biotics initiated. Liberal use of x-rays or magnetic
resonance imaging aids in evaluation of biomechan-
ical abnormalities, foreign bodies, and the presence
of osteomyelitis. For stable, clean wounds, optimi-
zation of the limb’s vascular status should be pur-
sued prior to reconstruction. A multidisciplinary
approach is needed to effectively treat all aspects
of the diabetic foot pathology, including pedor-
thotists, prosthetists, infectious disease, endocrine,
medicine, podiatry, orthopedics, vascular surgery,
wound nursing, and plastic surgery.

With respect to acutely traumatized lower
extremities, the majority are first treated by ortho-
pedic surgeons, who prioritize bony stabilization.
Many studies have demonstrated the importance of
early intervention to preserve soft tissues and cover
open fractures in preventing complications, such as
infection, delayed wound healing, or amputation.
A multidisciplinary approach utilizing orthopedic,
trauma, vascular, and plastic surgery teams is crucial
to achieve the goal of preserving a functional lower
limb. Treatment considerations include assessing
the degree of vascular injury, contamination, frac-
ture patterns and the amount of comminution, and
the size of the soft tissue defect. Ideally, bones will
be stabilized, aggressive wound debridement will be
performed, and soft tissue reconstruction will then
follow. Close communication with the physician
treating the bony injury is critical to avoid unneces-
sary amputations as often plastic surgery capabili-
ties in wound coverage are not divulged early in the
treatment period.
Other wound etiologies include venous
stasis, autoimmune processes, and ischemia.
­ 7. Apply methylene blue to the wound using a
Reconstruction of these wounds typically starts
with debridement, followed by simpler techniques
for wound closure. If bypass is required, this should
be done first, and debridement and reconstruction
should be performed at least 2 weeks after bypass.
Partnering with rheumotology is paramount for the
autoimmune wounds. Wound nurses can be helpful
with venous stasis patients who require compression
dressings to promote healing.
This chapter outlines a stepwise approach to
the surgical treatment of lower extremity wounds,
beginning with diabetic foot ulcers and followed
by soft tissue reconstruction of the traumatized
lower extremity.
DIABETIC FOOT WOUND
RECONSTRUCTION
Preoperative markings
Doppler and trace the course of the anterior tib-
ial/dorsalis pedis artery and the posterior tibial
artery with its medial and lateral plantar branches.
Handheld Doppler can be used to evaluate antero-
grade flow in either the anterior or posterior tibial
arteries by listening for signal in one vessel while
compressing the other. Compression prevents
­retrograde flow through communicating branches.
Diabetic foot wound reconstruction  19
Intraoperative details
of debridement
1. Place patient supine on the operating room
table for all wounds except wounds to the
posterior heel or Achilles.
2. Wrap upper thigh with 3–5 layers of soft cot-
ton roll substitute.
3. Place an appropriately sized pneumatic tour-
niquet on the upper thigh over the cotton pad-
ding. Set the tourniquet to 285 mmHg but do
not inflate. The tourniquet is placed as a safety
measure only. Tourniquets should be avoided
in vascular patients.
4. Swab the wound with aerobic and anaerobic
culture swabs. Label these cultures as “pre-
debridement.” These pre-debridement cultures
should be obtained prior to the prep.
5. Prep and drape the foot and ankle circumfer-
entially to the knee.
6. Wipe the prep solution off the wound with a
saline-moistened laparotomy pad.
Q-tip or laparotomy pad until the wound is
coated with a thin layer of blue staining. If the
wound has a sinus tract, a small amount of
methylene blue can be injected into the sinus
tract with a blunt angiocatheter. This will
stain the tissue to ensure that the debridement
is complete. Follow this maneuver with hydro-
gen peroxide, which will facilitate the staining
of the tissues with the dye.
8. Using a scalpel, sharply excise the edge of
the wound until healthy, bleeding tissue
is noted. Excise at least a depth of 5 mm
so that any penetrating biofilm is excised
adequately.
9. If Versajet™ (Smith & Nephew, London, UK)
hydrosurgery system is available, debride the
base of the wound until healthy, bleeding
tissue is noted. Be sure to remove all blue-
stained tissue.
10. If Versajet is unavailable, use curettes or
a knife to debride the base of the wound,
­ensuring all blue-stained tissue is removed.
11. If bone is involved in the wound, use rongeurs
to debride the bone, making sure to send the
bone to both microbiology for culture and
pathology for determination of osteomyelitis
(pre-debridement). Any uneven bone edges
should be smoothed with either a bone rasp
20  Lower extremity reconstruction
or pineapple mechanical burr, using water
irrigation during the process to avoid thermal
injury.
12. Obtain hemostasis using judicious
electrocautery.
13. Pressure irrigate the wound with a minimum
of 3 L of normal saline.
14. Put on new sterile gloves. Place new sterile
drapes.
15. For the remainder of the case, use clean
instruments.
16. Swab the wound again for aerobic and anaero-
bic cultures (post-debridement). It is best to
obtain tissue for culture.
17. If bone is involved in the wound, use a ron-
geur to biopsy the bone and send for culture
(post-debridement).
18. If the wound was grossly infected or had bac-
terial growth on previous post-debridement
cultures, the wound should not be closed at
this time. Place either wet-to-dry dressings or
a negative-pressure wound therapy (NPWT)
device and plan for return to the operating
room in next couple of days for staged closure.
19. If the wound has no growth from previous
post-debridement cultures, it is ready for
closure.
20. Apply a plaster posterior splint with the foot
in 90° dorsiflexion, taking care to pad the heel
well if reconstruction was performed.
Postoperative details
Patients should maintain non-weight-bearing
status on the affected extremity. Postoperative
x-rays can be helpful in osteomyelitis patients,
particularly after large bone resections, so
that the new bone anatomy may be delineated.
Limb e­ levation is encouraged to reduce edema.
Limitations of ambulation and mobility place
patients at risk for thromboembolic events.
As  such, mechanical and chemoprophylactic
measures should be taken to reduce the risk of
deep vein thrombosis (DVT). Antibiotics are
tailored according to operative c­ ultures. NPWT
dressings should be changed cleanly at the bed-
side every 3 days to assess wound healing. Serial
operative debridements spaced 24–72  hours
apart are performed until all necrotic tissue and
odor are absent from the wound.
FOREFOOT PLANTAR ULCERS:
ACHILLES LENGTHENING, FILLET
OF TOE FLAPS
Forefoot plantar ulcers typically develop under
metatarsal heads and are associated with increased
pressures during gait as a result of stiffness of the
Achilles tendon (triceps surae) and equinus defor-
mity. Often, if the ulcer does not directly involve
the bony prominence, tendo-Achilles lengthening
or gastrocnemius recession along with thorough
soft tissue debridement of the ulcer are sufficient
to allow healing by secondary intention. Patients
who are unable to dorsiflex beyond neutral with
the knee in either the flexed or extended posi-
tion should undergo tendo-Achilles lengthening,
whereas patients able to dorsiflex beyond neutral
only with the knee flexed demonstrate stiffness
of the gastrocnemius portion of the tendon and
should undergo gastrocnemius recession. It is
important to avoid excessive lengthening because
this may lead to calcaneal gait and heel ulcers.
When forefoot wounds involve one or more
phalanges, it can be helpful to preserve the soft tis-
sues of each toe for the purposes of flap closure.
Depending on the anatomy, the fifth toe may be
small, and this tissue may not be enough to use for
closure.
Preoperative markings
1. Identify the insertion of the Achilles tendon
on the posterior calcaneal tuberosity.
2. Mark the medial and lateral edges of the
Achilles tendon.
3. Mark three points along the central raphe of
the tendon at 3, 6, and 9 cm proximal to the
calcaneal insertion (percutaneous tendo-
Achilles lengthening).
4. Mark the distal extent of the gastrocnemius
muscle belly (gastrocnemius recession).
Intraoperative details of
percutaneous tendo-Achilles
lengthening
1. The patient may be positioned supine on the
operating room table.
2. The foot and leg are prepped and draped
­circumferentially to the knee.
 Forefoot plantar ulcers: Achilles lengthening, fillet of toe flaps  21
3. Elevate the leg and gently dorsiflex the foot.
4. Using a #15 scalpel, make the first stab
incision at the 3-cm mark in a longitudinal
fashion.
5. Turn the blade 90° medially and hemisect the
tendon.
6. Make a stab incision at the 6-cm mark and
turn the blade laterally to hemisect the
tendon.
7. Make a stab incision at the 9-cm mark and
turn the blade medially again to hemisect the
tendon.
8. Maximally dorsiflex the foot until the tendon
is released. Indentations along the edge of the
tendon corresponding with each stab incision
will be palpable when the hemisections are
complete.
9. Close each stab incision with a single simple
stitch using 3-0 or 4-0 Prolene® (Ethicon,
Somerville, NJ).
10. Apply sterile dressing to each incision and a
plaster posterior splint with foot in 90° dorsi-
flexion, taking care to pad the heel.
Intraoperative details of
gastrocnemius recession
1. The patient may be positioned supine on the
operating room table.
2. The foot and leg are prepped and draped cir-
cumferentially to the knee.
3. Elevate the leg and dorsiflex the foot.
4 . Make a 5-cm posteriomedial longitudinal
incision, beginning just distal to the gas­
trocnemius indentation and extend
proximally.
5. Dissect through subcutaneous tissues to the
deep fascia, taking care to preserve saphenous
vein.
6. Incise the deep fascia longitudinally.
7. Bluntly dissect the soleus muscle from
the ­gastrocnemius tendon medially to
­laterally, taking care to protect the sural
nerve if identified deep to the fascia at this
point.
8. Transversely transect the gastrocnemius
tendon completely. The tendon edges will
separate 1–2 cm, indicating complete release.
9. If the plantaris tendon is felt medially, it
should be transected as well.
10. Close the deep fascia with 2-0 Vicryl®
(Ethicon).
11. Close the skin incision with 3-0 Prolene in a
vertical mattress fashion.
12. Apply sterile dressings and a plaster posterior
splint with foot in 90° dorsiflexion, taking
care to pad the heel.
Postoperative details
Patients are kept non-weight bearing for 1 week,
then in a CAM (controlled ankle motion) walker
boot for the next 5 weeks.
Intraoperative details of a toe fillet flap
1. Prep, drape, and debride the wound as previ-
ously described, removing all necrotic tissue.
2. Measure the size of the wound for proper flap
planning.
3. Plan to take your flap from a toe adjacent to
the wound.
4. Map the medial and lateral plantar digital
neurovascular bundles.
5. Make a plantar longitudinal incision and
elevate the flap beginning distally off the
distal phalanx and flexor tendons back to the
metarsophalangeal joint (MPJ). Follow the
neurovascular bundles back to the adjacent
web spaces.
6. Make a connecting incision to the wound, to
be covered if needed.
7. Disarticulate the toe at the metatarsal phalan-
geal joint and use the dorsal skin to flap down
and cover the donor site. Ensure removal of
the nail plate, nail bed, and any phalangeal
bone within the flap tissue.
8. Carefully place the remaining flap over the
wound, making sure to not cause excess
tension or pressure on the neurovascular
bundles.
9. Use skin sutures to secure the flap to the
wound.
Postoperative details
Avoid compression on the local flap. Viability of
the flap should be regularly monitored with fre-
quent capillary refill checks to ensure there is no
excessive pallor or congestion.
22  Lower extremity reconstruction
MIDFOOT PLANTAR ULCERS:
PRIMARY CLOSURE, SKIN
GRAFTING, LOCAL FLAPS
The medial plantar midfoot is normally a non-
weight-bearing region. Soft tissue defects in this
area can be easily treated with skin grafting; how-
ever, in diabetic patients, plantar ulcers of the
midfoot generally occur in the setting of Charcot
deformity and bony arch collapse. Skin grafts
provide inadequate soft tissue coverage and are
prone to breakdown when ulcers are associated
with exostosis or other bony prominences but are
easy and reliable options for non-weight-bearing
regions. After midfoot stabilization and exostec-
tomy, pressure points may be fully neutralized, and
small ulcers can heal by skin graft or ­secondary
intention. Although wounds may close by second-
ary intention, this can result in an unstable scar
and recurrent breakdown. Due to the relatively
inelastic quality of plantar foot skin, only small
ulcers tend to be amenable to primary c­ losure, and
more generally local flaps, including V-Y and rota-
tion flaps, are employed for durable wound cov-
erage and replacement of “like tissue with like.”
Appropriate utilization of pedal local flaps requires
knowledge of normal vascular anatomy and angio-
somes. Perforating vessels should be identified and
marked with a handheld Doppler. In addition,
rotation flaps, although a random pattern, may be
based on blood flow from axial vessels.
Intraoperative details of primary
closure (rare)
1. Prep, drape, and debride the wound as previ-
ously described.
2. The weight-bearing region of the plantar foot
has thick glabrous skin with fibrous subcu-
taneous adhesions. To close a plantar foot
wound primarily without tension, judicious
undermining of skin flaps using electrocau-
tery or sharp dissection may be necessary.
3. Interrupted vertical mattress sutures using
2-0 Prolene on a CT-1 (Ethicon) taper needle
are placed to evert skin edges and obtain
tension-free wound edge approximation.
Avoid excessive pressure on the skin edge with
forceps.
4. Dry, sterile dressings are applied.
Antibacterial ointments or
petroleum-moistened gauze dressings can
cause maceration and are avoided on the plan-
tar foot incision.
5. Apply a plaster posterior splint with the
foot in 90° dorsiflexion, taking care to pad
the heel and non-weight-bearing areas
postoperatively.
Intraoperative details of
split-thickness skin grafting
1. Clip the hairs and prep the upper thigh (donor
site).
2. Prep, drape, and debride the wound as previ-
ously described.
3. Measure the dimensions of the wound; ensure
there is no denuded bone or tendon exposed.
4. Mark the size of the skin graft needed on the
donor site.
5. Assemble the power dermatome with appro-
priate size guard, setting the thickness of the
graft at 0.014–0.018 in.
6. Optional step: Infiltrate the donor site with 1%
lidocaine with 1:100,000 epinephrine diluted
in normal saline.
7. Wipe away the prep solution from the thigh
with a saline-dampened laparotomy pad.
8. Lubricate the donor site and dermatome with
mineral oil.
9. Have an assistant apply traction to the donor
site to create a flat, even donor surface.
10. Using slow/steady pressure on maximum
power, harvest the split-thickness skin graft.
If using the thigh as a donor site, always har-
vest the graft from a more superior position to
further conceal the graft if the patient wears
shorts or a skirt (female).
11. Place the graft on a dermal carrier and mesh
the skin graft using the mesher in a 1:1.5 ratio
or “piecrust” the graft with a #11 scalpel.
12. The thigh can be closed primarily if the width
of the skin graft is small enough to allow for
skin closure. Primary closure of thigh donor
sites should be done if at all possible as they
heal with much less pain. Alternatively, if
the patient is a female and there is redundant
abdominal wall tissue, a mini-­abdominoplasty
may be performed and skin graft harvested
from the specimen.
13. Apply the skin graft to the wound bed, mini-
mizing the separation of the interstices.
 Midfoot plantar ulcers: Primary closure, skin grafting, local flaps  23
14. Secure the skin graft with either skin staples
or 3-0 running Monocryl® (Ethicon) or
­chromic suture.
15. Apply a nonstick barrier such as Mepitel®
(Mölnlycke, Gothenburg, Sweden), xeroform,
or Adaptic® (Systagenix, San Antonio, TX) to
the skin graft, followed by NPWT if desired.
16. Apply a plaster posterior splint with the foot in
90° dorsiflexion, taking care to pad the heel.
17. Apply sterile, semi-occlusive dressing to the
skin graft donor site.
Intraoperative details of the V-Y
advancement flap
1. Prep, drape, and debride the wound as previ-
ously described.
2. To maintain a bloodless field and allow for
easy identification of perforators, flap dissec-
tion is performed under tourniquet control.
3. Elevate and gravity exsanguinate the extrem-
ity for 2 minutes.
4. Inflate the tourniquet to 285 mmHg in
patients who have not undergone a distal
bypass procedure.
5. Orient the V flap in a manner such that it
will advance in the direction of greatest skin
elasticity, incorporating any known cutaneous
perforators and respecting known angiosome
boundaries.
6. The wound may need to be excised along the
axis of the V flap to increase the width of the
flap, which will increase the blood supply to
the V flap.
7. Incise skin and subcutaneous tissues down to
and including plantar fascia.
8. If necessary for flap mobility, judiciously
undermine the flap in the subfascial plane,
(a)  
Figure 3.1  (a) Plantar rotational flap based medially on the medial plantar artery blood supply to close
a culture-negative diabetic plantar ulcer. (b) Flap rotated into place with split-thickness skin graft to
the donor defect.
releasing fascial septations but preserving
perforating vessels.
9. Advance the flap to oppose wound edges
without tension.
1 0. Deflate the tourniquet and obtain hemostasis.
11. Close the skin with 2-0 Prolene in an inter-
rupted vertical mattress fashion, beginning
with the distal flap.
1 2. Apply a sterile dressing.
13. Apply a plaster posterior splint with the
foot in 90° dorsiflexion, taking care to pad
the heel.
14. Commonly, only 1–2 cm is gained for a
V-Y flap advancement procedure in the
plantar foot.
Postoperative details
When NPWT devices are used to secure skin
grafts, they are removed carefully at the bedside
on postoperative day 4 to assess skin graft take.
A petroleum-impregnated gauze is applied to the
graft and changed daily to keep it moist. Donor site
dressings are left in place for 10–14 days to allow
undisturbed epithelialization.
Intraoperative details of random
pattern rotation plantar foot flaps
1. Prep, drape, and debride the wound as previ-
ously described.
2. Design a semicircular arc flap close to the
wound that can be rotated around a pivot
point to cover the wound (Figure 3.1a).
3. Make an incision along the planned flap lines
with a #15 blade down to and including the
plantar fascia.
(b)
24  Lower extremity reconstruction
Figure 3.2  Four months after surgical inter-
vention. A total-contact cast was used for
2 months prior to allowing the patient to
­ambulate independently.
4. Gently free the flap in this subfascial plane so
that it can be rotated to cover the defect.
5. If there is excessive tension on the flap, a back
cut can be made at the end of the arc opposite
from where the defect is to reduce tension.
6. The new defect created by rotating the flap
should be closed with a split-­t hickness skin
graft as closing this primarily will put t­ ension
on the flap away from the defect (Figure 3.1b).
Postoperative details of a random
pattern rotation plantar foot flap
Nonstick sterile dressings are applied to the flap. Care
is taken to avoid compression of the flap. Patients
should be strictly non-weight bearing. Monitor the
flap closely for signs of ischemia. Figure 3.2 shows a
patient 4 months posteroperatively.
HINDFOOT PLANTAR ULCERS:
ABDUCTOR HALLUCIS, ABDUCTOR
DIGITI MINIMI, FLEXOR DIGITORUM
BREVIS, CALCENECTOMY, MEDIAL
PLANTAR ARTERY FLAPS
Plantar heel ulcers in diabetic patients ­present a par-
ticularly difficult reconstructive ­ challenge (loupe
magnification is strongly advised for all intrinsic
flaps of the foot). The heel is weight bearing, and in
ambulatory patients, the presence of an ulcer may
indicate laxity of the Achilles tendon complex and
calcaneal gait (Figure  3.3a). In  ­addition, because of
the dual blood supply to the heel, nonhealing ulcers
may reflect severe vascular disease. Depending on
the depth of heel ulcers and the presence of osteomy-
elitis, distally based V-Y advancement flaps as well as
intrinsic muscle flaps with skin graft can be used for
soft tissue reconstruction. Free flap reconstruction is
commonly performed for large heel ulcers when there
are no other options. Local muscle flaps used for the
reconstruction of plantar foot wounds have included
abductor hallucis, abductor digiti minimi, and flexor
digitorum brevis. Source vessel patency and ante-
grade flow should be confirmed prior to muscle har-
vest. Intraoperative use of Doppler should occur after
the muscle is mobilized and rotated into the defect
to ensure viability of the muscle. For nonambulators,
aggressive calcenectomy can be performed to allow
for more soft tissue ­mobilization and primary closure
of superficial wounds. If the medial plantar artery is
patent, a medial plantar artery flap may be one of the
best options for closure of heel wounds because it can
be sensate and highly durable (Figure 3.3b). Ilizarov
frames or external fixators are useful adjuncts for
immobilization and pressure offloading following
local pedal flaps.
Intraoperative details of the medial
plantar artery flap
The medial plantar artery flap is commonly used
for heel defects since the flap, which is based on the
medial plantar artery, is readily transferred poste-
rior upon harvest. A Doppler should be used to con-
firm patency of the medial plantar artery or MRA/
angiogram is performed preoperatively as well.
A skin graft is then placed on the midfoot donor site.
1. Prep, drape, and debride the wound as previ-
ously described.
2. Outline the recipient site defect so that these
dimensions are marked on the midfoot plan-
tar skin (Figure 3.3a).
3. A Doppler should be used intraoperatively
to confirm the preoperative examination of
medial plantar artery patency.
4. The skin paddle is then incised down to the
plantar fascia and the flap raised from distal
to proximal (Figure 3.3b).
5. The medial plantar vascular pedicle must be
raised with the flap and identified distally if pos-
sible (loupe magnification is strongly advised).

(a)  
Figure 3.3  (a) Calcaneal osteomyelitis defect (following debridement and negative final histopathol-
ogy) planned medial plantar artery flap in diabetic male. (b) Medial plantar artery flap raised on its
vascular pedicle.
Figure 3.4  Patient shown 5 months after the
surgery with a healed flap; the patient ambulates
without assistance.
6. The vascular pedicle is encountered between
the heads of the flexor hallucis brevis and
abductor hallucis muscles.
7. A cutaneous nerve may be harvested with the
flap to provide sensation.
8. The flap is rotated posteriorly into the defect,
and a meshed skin graft is placed in the mid-
foot defect (Figure 3.4).
Skin substitutes  25
(b)
Notes
Vascular optimization of the affected limb is
essential for healing. Wound location and charac-
teristics will dictate the appropriate reconstructive
procedure. Loupe magnification is necessary when
performing local pedal muscle flaps.
SKIN SUBSTITUTES
Skin substitutes have a variety of indications
for difficult-to-heal wounds. These may include
chronic diabetic foot ulcers, venous leg wounds,
or even full-thickness wounds. These products
are more useful in the sick patients who can-
not undergo more definitive closure techniques.
The three major skin substitutes commonly used
are Apligraf  ® (Organogenesis, Canton, MA);
Dermagraft ® (Organogenesis); and Integra™
(Integra LifeSciences, Plainsboro, NJ). Apligraf
is a  bilayer living cell product made from fetal
foreskin. Dermagraft is a cryopreserved human
fibroblast-derived dermal substitute that also
­
comes from neonatal foreskin. Integra bilayer
wound dressing is an acellular porous matrix of
cross-linked bovine tendon collagen and glycos-
aminoglycan and a semi-permeable polysiloxane
(silicone layer). The silicone layer adds strength,
moisture control, and a flexible adherent dress-
ing. Integra is the only substitute of the three that
is indicated for full-thickness wounds and is use-
ful to obtain dermal coverage of tendons and bone
with intact periosteum.
26  Lower extremity reconstruction

Intraoperative details of Integra
Bilayer Matrix wound
dressing application
1. Prep, drape, and debride the wound as previ-
ously described, removing all necrotic tissue.
2. Achieve hemostasis.
3. Measure the dimensions of the wound; bone
with intact periosteum or exposed tendon is
acceptable for this product.
4. Check the expiration date on the Integra and
open onto the sterile field.
(a)
5. Peel open the foil pouch and, while holding
the center tab, carefully remove the two poly-
ethylene sheets.
6. Use the center tab to move the graft to the
saline bath and carefully separate the graft
into the saline to soak for 1–2 minutes.
7. The graft may be meshed with a mesher in the
same way as for a split-thickness skin graft as
described previously.
8. Apply the graft to the wound silicone side up.
9. Staple or suture the periphery of the graft to
the wound edges approximately every 1–2 cm
apart.
10. Trim the edges of the graft and apply gentle (b)
pressure with a sponge to press the center of
the graft down against the wound base. Figure 3.5  (a) Well-vascularized appearance of
Integra. The superficial silicone layer is ready to be
11. Apply a moist antimicrobial dressing followed
removed after 3 weeks. Previously exposed exten-
by sterile gauze dressing and a moderate com- sor hallucis longus and anterior tibialis t­ endon.
pressive dressing and offload if needed. (b) Split-thickness skin graft applied to dorsal foot
wound following treatment with Integra.
Postoperative details
with local flap options than distal-third defects.
Inspect the wound in 48 hours by changing the Options for distal-third open tibial fractures with
outer dressing to assess for hematoma. Drain if soft tissue defects have traditionally been free tis-
necessary. Continue to change the outer dress- sue transfer; however, many defects are now man-
ing at least every 72 hours to assess for infection aged with distally based flaps, such as the sural
and to remoisten antimicrobial dressings. The fasciocutaneous and soleus muscle.
Integra should be fully vascularized by 21 days
(salmon pink appearance), at which time the sili- Timing of lower extremity trauma
cone layer is removed, and the wound is ready for a
split-thickness skin graft (Figures 3.5a, b). Although many trauma cases are treated as soon
as possible, the literature reveals that only com-
TRAUMATIC LOWER EXTREMITY partment syndrome must be treated emergently.
WOUND RECONSTRUCTION This means that fasciotomies should be performed
within 6 hours. This also means that open frac-
A soft tissue reconstructive option for the lower ture reduction and debridement do not necessar-
extremity can be guided by dividing the leg into ily need  to be performed within 6 hours of the
proximal, middle, and distal thirds. Proximal- injury. These cases can easily be delayed up to
and middle-third defects are more easily treated 24 hours, and some literature reports delays of up

to and beyond 72 hours without adverse effects.
This should be taken into consideration in cases of
­polytrauma or when scheduling is difficult.
Intramedullary nail versus
external fixation
Intramedullary nail and external fixation can both
be used successfully for rapid fixation of tibial frac-
tures without the need for extensive soft tissue dis-
section. Intramedullary nails have been shown to
have lower rates of infection, malunion, and non-
union, except for cases with severe comminution
or for proximal tibial fractures. In the acute set-
ting, complex, comminuted open fractures can be
brought out to length and stabilized with external
fixation at the time of first debridement. Often, fix-
ation can be converted to an intramedullary nail
by the orthopedic surgeon at the time of definitive
soft tissue closure.
Fasciotomies for compartment
syndrome of the lower leg
PREOPERATIVE MARKINGS
1. Anterolateral incision is placed longitudi-
nally 2 cm anterior to the fibula shaft and is
approximately 15 cm in length.
2. Posteriomedial incision is placed longitudi-
nally 2 cm posterior to the posterior medial
palpable edge of the tibia and is 15 cm in
length.
INTRAOPERATIVE DETAILS OF
FASCIOTOMIES OF THE LOWER LEG
1. Place the patient supine on the operating
room table.
2. Prep and drape in the standard fashion.
3. Plan and make incisions as described previ-
ously with a #15 blade.
4. Through the anterolateral incision, use blunt
scissors to dissect down to the level of the
intermuscular septum.
5. Release the anterior compartment by mak-
ing a small nick in the anterior intermuscular
septum midway between the septum and the
tibial crest.
6. Extend the release for 15 cm using blunt-tip
scissors by aiming for the patella proximally
and the center of the ankle joint distally.
Traumatic lower extremity wound reconstruction  27
7. Release the lateral compartment by making a
nick posterior to the intermuscular septum in
line with the fibula shaft.
8. Extend the release for 15 cm using blunt-tip
scissors by aiming for the lateral malleolus
distally to ensure that dissection will be
­posterior to the superficial peroneal nerve.
9. Through the posteriomedial incision, use
blunt scissors to dissect down to fascia.
10. Identify and retract the saphenous nerve and
vein.
11. Release the superficial posterior compartment
approximately 15 cm with blunt-tip scissors in
a linear fashion.
12. Through the same incision, detach the soleal
bridge at the origin of the soleus muscle and
retract it to expose the fascia covering the tibialis
posterior and flexor digitorum longus muscles.
13. Release the deep posterior compartment in a
linear fashion by following the course of the
flexor digitorum longus muscle.
14. Fascial layers are not closed.
15. Options for skin closure include primary
closure of the skin, NPWT over open wounds
until delayed closure with a split-thickness
skin graft, or assisted wound closure tech-
niques (the medial incision is commonly
closed prior to the lateral incision).
POSTOPERATIVE DETAILS FOR
FASCIOTOMIES OF THE LOWER EXTREMITY
If skin incisions are left open, proper wound care
and follow-up are imperative. Regular dressing
changes or use of NPWT will help reduce inci-
dences of infection. If compartmental pressures
were elevated for a significant time prior to sur-
gery, muscle death and other soft tissue necrosis
must be thoroughly debrided prior to skin closure.
Knee and upper third of leg
coverage: Medial or lateral
gastrocnemius flap
INDICATION
Proximal-third complex leg wound with exposed
bone, hardware, or patella tendon.
PREOPERATIVE MARKINGS
Longitudinal incision in the midline of the poste-
rior calf, from the popliteal fossa to 10 cm above
the ankle joint.
28  Lower extremity reconstruction
INTRAOPERATIVE DETAILS OF MEDIAL
GASTROCNEMIUS FLAP
1. Place the patient supine or prone on the oper-
ating room table.
2. Place a well-padded thigh tourniquet on the
correct limb.
3. Prep and drape in the standard fashion.
4. Gravity exsanguinate the limb and inflate
tourniquet if desired.
5. Debride wound site as needed (Figure 3.6a).
6. Plan and make incisions as described with
a #15 blade. If a skin island is planned, it is
placed over the distal muscle belly in either
the longitudinal or transverse orientation.
7. Deepen the incision down to the superficial
surface of the muscle.
8. Proximally, the medial gastrocnemius
is easily separated from the underly-
ing soleus in a natural plane. The plan-
taris tendon is visualized in this space.
(a)  
(c)
Figure 3.6  (a) Freshly debrided proximal-third leg wound with tibial fracture and exposed hardware.
(b) Harvested medial and lateral gastrocnemius muscle bellies. (c) Well-healed medial gastrocnemius
muscle.
Take care to protect the greater saphenous
vein in the subcutaneous tissues medial to the
medial gastrocnemius muscle belly.
9. Dissection proceeds from proximal to the
distal insertion on the Achilles tendon.
10. Transect the medial aspect of the Achilles
tendon for a medial gastrocnemius flap and
laterally for a lateral gastrocnemius flap
(if harvesting a lateral gastrocnemius flap,
be careful to look for and not injure the
­common peroneal nerve).
11. The midline raphe is identified on the under-
surface and superficial surface of the muscle.
Care is taken to identify and protect the lesser
saphenous vein and sural nerve along the
midline raphe.
12. Sharply incise the midline to separate the
medial gastrocnemius from the lateral
(Figure 3.6b).
13. Rotate the flap to the area to be covered.
(b)
 Traumatic lower extremity wound reconstruction  29

14. The tunnel can be opened and the muscle
drapes over this, or the muscle can be
rotated under a subcutaneous tunnel
(if this is performed, ensure that there
is plenty of space in the tunnel so that
undue compression is not placed on the
muscle as it will lead to venous congestion
of the muscle flap).
15. If a greater arc of rotation is required (to reach
the proximal knee or distal thigh), the pedicle
can be skeletonized along the proximal
undersurface of the muscle and its origin
transected.
16. Suture in place with absorbable sutures.
17. A split-thickness skin graft can be used to
cover the muscle flap or donor site if a skin
island is used.
POSTOPERATIVE DETAILS
Flexion and extension of the knee should be lim-
ited with use of a knee immobilizer for 4 weeks.
If skin grafting was necessary, bolster or NPWT
dressing is continued for 4 days and then removed
to assess graft take (Figure 3.6c).
Middle third of lower extremity
defect: Soleus flap
INDICATION
Middle- or distal-third complex leg wound with
exposed bone or hardware.
PREOPERATIVE MARKING
Longitudinal incision 2 cm medial to the medial
tibial border.
INTRAOPERATIVE DETAILS OF THE
SOLEUS FLAP
1. Place the patient supine or prone on the oper-
ating room table.
2. Place a well-padded thigh tourniquet on the
correct limb if desired.
3. Prep and drape in the standard fashion.
4. Gravity exsanguinate the limb and inflate
tourniquet if desired.
5. Debride wound as needed (Figure 3.7a).
6. Plan and make incisions as described with a
#15 blade or use existing wound and extend
incision in line along medial border of tibia.

(a)

(b) (c)

Figure 3.7  (a) Middle-third complex leg wound with exposed tibial hardware and injured but intact
gastrocnemius muscle (intact posterior tibial artery on preoperative angiogram). (b) Soleus muscle
is transposed to cover the previously exposed hardware. The muscle is then covered with a split-­
thickness skin graft. (c) Patient is shown with healing after 7 months; the patient was ambulating
without difficulty.
30  Lower extremity reconstruction
7. The soleus is located deep to the gastrocne-
mius and plantaris tendons in the superficial
compartment of the leg.
8. Divide the muscle at the midline if perform-
ing a hemisoleus flap and dissect it away from
the deeper flexor digitorum longus.
9. Distally, separate the soleus from the Achilles
tendon on the superficial surface of the
muscle.
10. Ligate distal perforators from the posterior
tibial artery.
11. Rotate the flap to the area to be covered
(fascial incisions may be made to increase the
surface area of the transferred flap as shown
in Figure 3.7b).
12. Suture in place with absorbable sutures.
13. A split-thickness skin graft can be used to
cover the muscle flap.
POSTOPERATIVE DETAILS
If NPWT is used to secure a split-thickness skin
graft, it is continued for 4 days postoperatively
and then removed to assess graft take. Muscle is
assessed for signs of ischemia or congestion. Leg
elevation and non-weight bearing with strict knee
immobilization are mandatory in the immediate
postoperative period. Figure  3.7c shows a patient
ambulating 7 months postoperatively.
Free-flap reconstruction of lower
extremity wounds
Free tissue transfer has commonly been the
method of choice for defects that are distal in the
leg and foot. Commonly used free flaps have been
both muscle and fasciocutaneous, with the harvest
covered in many plastic surgery textbooks.
Recipient vessels are commonly the anterior
tibial artery and vein and the posterior tibial
artery and vein. Anastomosis outside the level
of injury in either an end-to-side fashion or end-
to-end fashion has not been shown to provide
any different outcome. In cases of Gustilo IIIC
injuries, commonly used recipient vessels are
the injured vessel proximal to the zone of injury.
Computerized tomographic angiography, mag-
netic resonance angiography, or angiography
should be performed to delineate the arterial vas-
culature prior to surgery, particularly in cases of
tibial fractures.
Rectus abdominis free flap
INDICATION
Free muscle transfer is indicated for the treatment
of complex distal leg wounds where local options
for durable soft tissue coverage is limited. The rec-
tus abdominis muscle is relatively quick and easy
to harvest. It provides moderate muscle bulk; how-
ever, there is associated donor site morbidity in
the form of abdominal wall weakness with flexion
and bulging. This flap is not commonly used now
that perforator-based fasciocutaneous flaps with
much less donor site morbidity are more popular.
However, in the plantar aspect of the foot, some
surgeons prefer a muscle-based flap with skin graft
and not a perforator fasciocutaneous flap.
PREOPERATIVE MARKINGS
1. Mark the abdominal midline from xyphoid to
pubis symphysis.
2. The choice of skin incisions includes midline,
paramedian, or low extended Pfannenstiel
incision.
INTRAOPERATIVE DETAILS FOR RECTUS
ABDOMINIS MUSCLE HARVEST
1. Position the patient supine on the operating
table.
2. Prep and drape the abdomen widely, from the
upper thighs to above the xyphoid. Include
the recipient site as well in the preparation.
3. Sharply cut skin and subcutaneous tissue
down to the abdominal fascia along the previ-
ously marked incision, which can be via an
extended Pfannenstiel, midline, or parame-
dian approach.
4. Judiciously undermine the skin and subcu-
taneous flaps to expose the anterior rectus
sheath along the length of the muscle.
5. Incise the anterior rectus fascia longitudinally
over the middle of the muscle.
6. Dissect the anterior rectus fascia off the mus-
cle to expose the medial and lateral borders of
the muscle, taking care not to traumatize the
fascia at the three inscriptions. If using Bovie
cautery, it should be on low energy; bipolar
cautery should also be used so that the muscle
is not traumatized. We recommend the use of
loupe magnification during the dissection.
7. Note that the motor nerves enter the muscle
laterally.

8. Bluntly dissect the muscle away from the
posterior rectus sheath.
9. Disoriginate the muscle from the xyphoid
and anterior sixth, seventh, and eighth costal
cartilages.
10. Superiorly, identify and ligate the deep supe-
rior epigastric artery and vein on the under-
surface of the muscle cephalad.
11. Identify the deep inferior epigastric artery and
vein entering the muscle inferiolaterally on
the undersurface of the muscle.
12. Disinsert the muscle from the pubic
symphysis.
13. Dissect out and hemaclip/ligate the pedicle as
close to the external iliac vessels as possible.
(a)  
(c)
Figure 3.8  (a) and (b) Preoperative view of traumatic injury to plantar aspect of foot. Exposed first
and fifth metatarsal bones. (c) Intraoperative view of rectus abdominus muscle harvesting via an
extended Pfannenstiel incision.
Traumatic lower extremity wound reconstruction  31
14. Transpose the flap to the recipient site for
microvascular anastomosis and flap insetting.
15. Close the anterior rectus sheath with figure-
of-eight permanent sutures, followed by a
running suture.
16. Close the abdominal subcutaneous tissue
and skin in layers over closed-suction drains
(Figure 3.8a–f).
Gracilis muscle free flap
INDICATION
Free muscle transfer is indicated for the treat-
ment of complex distal leg wounds where local
options for durable soft tissue coverage is limited.
(b)
(Continued)
32  Lower extremity reconstruction

(d)   (e)

(f )

Figure 3.8 (Continued)  (d) and (e) Injury site 2 years postoperatively; patient was ambulating without
assistance with durable reconstruction. (f) Donor site 2 years after surgery.

The  gracilis muscle provides small-to-moderate INTRAOPERATIVE DETAILS FOR GRACILIS

bulk, can be easily harvested, and is associated
with minimal donor site morbidity. Note that the
pedicle has variable length and circumference.
PREOPOPERATIVE MARKING
Draw a line from the origin of the adductor lon-
gus on the pubic tubercle to the medial tibial con-
dyle. The gracilis is two finger breadths inferior to
this line.
MUSCLE HARVEST
1. The patient is positioned supine on the operat-
ing table with leg abducted and hip and knee
flexed (frog-legged).
2. Prep and drape the entire leg
circumferentially.
3. Make a skin incision directly over the gracilis
muscle in the proximal thigh, inferior to the
adductor longus muscle.

4. Identify and preserve the greater saphenous
vein.
5. Incise the deep fascia over the gracilis muscle
belly.
6. Expose the muscle along the entire length of
the gracilis on the superficial surface.
7. Retract the adductor longus muscle laterally.
8. Identify the neurovascular bundle entering
the gracilis laterally and on the deep surface.
9. Dissect the medial femoral circumflex arterial
pedicle proximally, ligating branches that go
to the adductor longus and adductor magnus.
10. Disoriginate the gracilis from the pubic
tubercle proximally.
11. Transect the gracilis tendon distally.
12. Hemaclip and cut the pedicle as proximally as
possible and transpose the flap to the recipient
site for microvascular anastomosis and flap
insetting.
13. Close the donor site in layers over large-bore,
closed-suction drains.
14. For added muscle coverage, the gracilis can be
stretched by scoring the epimysium.
Latissimus dorsi free flap
INDICATIONS
Free muscle transfer is indicated for the treat-
ment of complex distal leg wounds where local
options for durable soft tissue coverage are lim-
ited. The latissimus dorsi is a large, superficial
muscle of the back that can be used to cover large
Figure 3.9  Preoperative marking of the latissimus dorsi muscle.
Traumatic lower extremity wound reconstruction  33
soft tissue defects and is easily tailored. Harvest
of the latissimus dorsi can be quick but requires
lateral decubitus positioning. Donor site morbid-
ity includes weakness of shoulder adduction and
upper arm extension and internal rotation. This
flap is not recommended in patients who are in a
wheelchair.
PREOPERATIVE MARKINGS
1. Mark the tip of the scapula, midline of the
back, iliac crest inferiorly, and anterior border
of the latissimus along the posterior axillary
line.
2. If a skin paddle is needed, it is designed along
the axis of the muscle (Figure 3.9).
INTRAOPERATIVE DETAILS FOR LATISSIMUS
DORSI MUSCLE HARVEST
1. Position the patient in lateral decubitus with
the operative site up, arm abducted, and elbow
flexed.
2. Be sure to place an axillary roll and pad pres-
sure points.
3. Prep and drape the arm and back widely.
4. Incise skin along the skin paddle.
5. Dissect down to the muscle.
6. Widely expose the superficial surface of the
muscle, undermining skin and subcutaneous
flaps.
7. Identify the anterior border of the muscle and
begin to dissect the undersurface of the latis-
simus away from the serratus anterior.
34  Lower extremity reconstruction
8. Identify and protect the thoracodorsal pedicle
on the undersurface of the muscle in the fatty
connective tissue near the axilla.
9. Disoriginate the latissimus from the thoraco-
lumbar fascia inferiorly and medially.
10. Inferiorly, take care not to violate the lumbar
fascia deep to the latissimus; otherwise, lum-
bar herniation may result.
11. Dissect the vascular pedicle on the undersur-
face of the latissimus as proximally as possible.
12. Identify the serratus branch (Figure 3.10) and
ligate.
13. Disinsert the latissimus.
14. Hemaclip and ligate the thoracodorsal pedicle.
15. Transpose the flap to the recipient site for
microvascular anastomosis and flap insetting.
16. Close the donor site in layers over at least two
large-bore, closed-suction drains.
POSTOPERATIVE DETAILS
For the gracilis, rectus, and latissimus free flaps, there
are no strict limitations on the donor site. Coughing
and straining should be kept to a minimum for
patients who undergo rectus abdominis muscle har-
vest. The recipient extremities should be kept elevated
for 10 days and non-weight bearing. Postoperative
flap monitoring involves a stay in the intensive care
unit for 3 days, where flap color, temperature, turgor,
and Doppler signal can be checked with frequency.
Figure 3.10  Serratus branch of the thoracodorsal artery.
Anterolateral thigh flap
INDICATIONS
Free anterolateral thigh (ALT) flap transfer is
indicated for the treatment of complex distal leg
wounds where local options for durable soft tis-
sue coverage is limited. The ALT flap has become
a workhorse flap for many institutions because of
its ease of harvest, minimal donor morbidity, and
predictability. Indications commonly include any
large soft tissue defect of the leg and foot except
for the plantar aspect due to its bulk and risk
of perforator shear injury compromising the skin
paddle. Care must be taken to avoid harvest in a
previously injured thigh. Patients with significant
atherosclerotic disease compromising the arterial
vasculature require preoperative evaluation using
angiography.
PREOPOPERATIVE MARKINGS
1. Markings for the ALT flap are based on the
location of the skin vessels that supply the
skin territory of the flap.
2. Important landmarks for the flap include the
anterior superior iliac spine and the superior
lateral border of the patella.
3. The flap is centered at the midpoint of a lon-
gitudinal line drawn between these two land-
marks. A circle with a 3-cm radius defines

the area at which the skin vessels, either
­septocutaneous vessels or musculocutaneous
perforators, exit.
4. The skin vessels are often found in the inferior
lateral quadrant of the circle.
5. The skin paddle is then designed around the
defined skin vessels.
INTRAOPERATIVE DETAILS FOR
ANTEROLATERAL THIGH FLAP HARVEST
1. Loupe magnification during dissection is rec-
ommended as it aids in locating the skin vessels,
avoids unnecessary injury to the pedicle, and
helps clearly visualize branches of the vessels.
2. The flap may be harvested as a suprafascial or
subfascial flap.
3. The medial incision is made down to and
through the thigh fascia, exposing the rectus
femoris muscle.
4. The epimysium of this muscle is preserved,
and the dissection proceeds in a lateral direc-
tion until the septum separating the rectus
femoris from the vastus lateralis is visualized.
5. The entire septum is exposed by retracting the
rectus femoris medially.
6. Branches of the descending branch of the
lateral femoral circumflex are observed either
perforating the vastus lateralis muscle or
traveling within the septum to reach the skin
of the anterolateral aspect of the thigh.
7. If the skin vessel is a musculocutaneous
perforator, then intramuscular dissection is
performed in the following manner: The point
of exit of the perforator is exposed, and the
muscle fibers anterior to the vessel are “lifted
up” using teeth forceps. The tenotomy scissors
are used to spread in a transverse plane over
the perforator, and the muscle fibers are cut.
8. Perforator dissection proceeds until its takeoff
from the descending branch of the lateral
femoral circumflex artery (LFCA) or further
until adequate pedicle length is achieved.
9. Once the cutaneous perforator has been
safely identified and dissected, the lateral skin
island incision is made and flap dissection
completed.
10. The pedicle is ligated proximally and the flap
transposed to the recipient site for microvas-
cular anastomosis.
11. The thigh donor site is closed primarily in lay-
ers over large-bore closed-suction drains.
CPT coding  35
12. If the flap width precludes tension-free closure
of the donor site, a skin graft is placed.
POSTOPERATIVE DETAILS
1. Drain output is monitored postoperatively,
and drains are removed when output is less
than 30 mL per day to decrease chance for
seroma formation.
2. If a skin graft was placed at the donor site, bed
rest is typically instituted until graft take.
3. Physical therapy rehabilitation of the lower
extremity is initiated once the donor site has
healed.
CPT CODING
11044 Debridement; skin, subcutaneous tissue,
muscle, and bone (first 20 sq cm)
11046 Next 20 sq cm
15004 Surgical preparation or creation of recipient
site by excision of open wounds, burn eschar, or
scar including subcutaneous tissue or incisional
release of scar contracture face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet
and/or multiple digits; first 100 sq cm or 1 per-
cent body area of infants and children
15120 Split-thickness autograft, face, scalp, eye-
lids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; first 100 sq cm or
less, or 1% of body area of infants and children
15342 Application of bilaminate skin substitute/
neodermis; 25 sq cm
15350 Application of allograft, skin; 100 sq cm
or less
14350 Adjacent tissue transfer or rearrangement,
finger or toe
14040 Adjacent tissue transfer or rearrangement,
forehead, cheeks, chin, mouth, neck, axilla,
genitalia, hands, and/or feet; defect 10 sq cm
or less
14041 Adjacent tissue transfer or rearrangement,
forehead, cheeks, chin, mouth, neck, axilla,
genitalia, hands, and/or feet; defect 10.1 to
30 sq cm
15738 Muscle, myocutaneous, or fasciocutaneous
flap; lower extremity
15756 Muscle or myocutaneous free flap
27602 Decompression fasciotomy, leg; anterior
and/or lateral, and posterior compartment(s)
15271 Application of skin substitute graft to
trunk, arms, legs, total wound surface area up
36  Lower extremity reconstruction
to 100 sq cm; first 25 sq cm or less of wound
surface area
15272 Each additional 25 sq cm wound surface
area or part thereof (list separately in addition
to code for primary procedure)
15273 Application of skin substitute graft to
trunk, arms, legs, total wound surface greater
than or equal to 100 sq cm; first 100 sq cm
wound surface area or 1% of body area of
infants and children
15274 Each additional 100 sq cm wound surface
area, or part thereof, or each additional 1%
of body area of infants and children, or part
thereof (list separately in addition to code for
primary procedure)
15275 Application of skin substitute graft to face,
scalp, feet, etc., total wound surface area up to
100 sq cm; first 25 sq cm or less
15276 Each additional 25 sq cm wound surface
area, or part thereof (list separately in addition
to code for primary procedure)
15277 Application of skin substitute graft to face,
scalp, feet, etc., total wound surface area greater
than or equal to 100 sq cm; first 100 sq cm
wound surface area, or 1% of body area of
infants and children
15278 Each additional 100 sq cm wound surface
area, or part thereof, or each additional 1%
of body area of infants and children, or part
thereof (list separately in addition to code for
primary procedure)
15170 Acellular dermal replacement
(i.e., Integra), trunk, arms, legs; first
100 sq cm or less, or 1% of body area of
infants and children
15171 Acellular dermal replacement, trunk,
arms, legs; each additional 100 sq cm, or each
additional 1% of body area of infants and chil-
dren, or part thereof (list separately in addition
to code for primary procedure)
15175 Acellular dermal replacement, face, scalp, eye-
lids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; first 100 sq cm or
less, or 1% of body area of infants and children
15176 Acellular dermal replacement, face, scalp, eye-
lids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; each additional
100 sq cm, or each additional 1% of body area of
infants and children, or part thereof (list sepa-
rately in addition to code for primary procedure)
Q4101 Skin substitute, Alpigraf, per sq cm [sup-
plied in 44 sq cm]
Q4104 Skin substitute, Integra Bilayer Matrix
Wound Dressing, per sq cm
Q4106 Skin substitute, Dermagraft, per sq cm
SUGGESTED READINGS
Clemens MW, Attinger CE. Functional recon-
struction of the diabetic foot. Semin Plast
Surg. 2010;24:43–56.
Ducic I, Attinger C. Foot and Ankle Reconstruction:
pedicled muscle flaps versus free flaps
and the role of diabetes. Plast Reconstr
Surg. 2011;128:173–180.
Hallock GG. Evidence-based medicine: lower
extremity acute trauma. Plast Reconstr Surg.
2013;132:1733–1741.
Hollenbeck ST, Woo S, Komatsu I, Erdmann D,
Zenn MR, Levin LS. Longitudinal outcomes
and application of the subunit principle to
165 foot and ankle free tissue transfers. Plast
Reconstr Surg. 2010;125:924–934.
 4
Chest wall reconstruction with
pectoralis major muscle flaps

RYAN TER LOUW AND KAREN KIM EVANS

Introduction 38 Notes 46
Preoperative markings 39 CPT coding 46
Intraoperative details 39 References 46
Postoperative details 46

INDICATIONS

1. Deep sternal wound infections 4. Dehisced median sternotomy wounds

2. Mediastinitis following open heart surgery 5. Intrathoracic dead space or bronchopleural
3. Soft tissue coverage of large sternal fistula
defects following trauma or oncologic 6. Chest wall reconstruction
resection 7. Head and neck reconstruction

Table 4.1  Special equipment

Supine, tuck arms
Preoperative culture-directed intravenous antibiotics (tailored for
gram-positive, gram-negative, and anaerobic coverage)
Irrigation: 3 L warm normal saline +/− antibiotic or dilute iodine or plain
Pulse irrigator
2.0 Prolene suture for skin
Retractors: Richardson’s, sweetheart, appendiceal
Rigid internal fixation system such as the Synthes or KLS system (if needed)
Electrocautery, long electrocautery tip
Rongeur and curettes
Periosteal elevator
Hemoclips: medium/large
Pencil Doppler probe
2 Blake drains
Abdominal binder, sized for chest wall

37
38  Chest wall reconstruction with pectoralis major muscle flaps

INTRODUCTION or mediastinitis is approximately 1–5% following

The pectoralis major flap was popularized in 1980
by Jurkiewicz for chest wall reconstruction; its
most notable contributions have been in decreasing
mortality and morbidity associated with sternal
wound infections following open heart surgery.1
The latissimus dorsi and rectus abdominus mus-
cles are other local reconstruction options; how-
ever, the pectoralis muscle remains the workhorse
flap for chest wall reconstruction due to its versa-
tility.2 The incidence of sternal wound infections
open heart surgery3 and will typically increase
length of hospitalization by 20 days and increase
the cost by three times compared to an uncompli-
cated postoperative course.4,5
Keeping the reconstructive ladder in mind,
local wound care does have its role in managing
sternal wound infections. Patients with wound
depth of less than 4 cm, negative blood cultures,
and minimal sternal exposure or instability can be
successfully managed with negative-pressure vac-
uum therapy (see Figure 4.1). The most important

(a)   (b)

(c)

Figure 4.1  Smaller superficial sternal wounds can be closed with VAC therapy, appropriate
­debridement, and primary or secondary closure. (a), (b) Superficial clean sternal wound treated with
VAC therapy. (c) Two weeks after primary closure of this defect.

predictor of vacuum-assisted closure (VAC) suc-
cess is wound depth less than 4 cm.6
Numerous studies have shown that early cov-
erage of sternal wounds with pectoralis flaps pro-
motes wound closure and sternal stability. The most
common indication for surgery is culture-positive
median sternotomy wound dehiscence.2 In  a
recent study reviewing 211 sternal wound infec-
tions, 95% of wounds were successfully closed with
an overall mortality rate of 5.7%. Mortality  rates
for deep sternal wound infections prior to pectora-
lis coverage approached 50%.7,8 Table 4.1 indicates
the equipment necessary for this surgery.
PREOPERATIVE MARKINGS
Borders of the pectoralis (see Figure 4.2):
●● Superior: clavicle
●● Lateral: anterior axillary line
●● Medial: sternum
●● Inferior: sixth rib
The thoracoacromial artery arises from the mid-
point of the clavicle and courses medially. The axis
of the pedicle follows a line drawn from the acro-
mion to the xiphoid. The thoracoacromial pedicle
arises from the second portion of the axillary
artery and travels underneath the pectoralis major
in the subfascial plane.
Figure 4.2  The thoracoacromial artery arises
from the midpoint of the clavicle and courses
medially. The axis of the pedicle follows a line
drawn from the acromion to the xiphoid. The tho-
racoacromial pedicle arises from the s­ econd por-
tion of the axillary artery and travels ­underneath
the pectoralis major in the subfascial plane.
Intraoperative details  39
INTRAOPERATIVE DETAILS
●● Introduction: There are several common varia-
tions of pectoral muscle flaps:
●● Advancement: The unipedicled pecto-
ralis major advancement flap is based
on the thoracoacromial artery. This will
advance the overlying skin component
along with the muscle (see Figure 4.3).
●● Turnover: The turnover pectoralis major
muscle flap is based on the internal mam-
mary artery (IMA) perforators penetrating
rib spaces 2 through 5 (see Figure 4.4).
●● Combinations of all have been used for sternal
reconstruction and closure with excellent
results.
●● Due to the success of rotation/­advancement
flaps in this area, microvascular s­ urgery
is rarely necessary in sternal wound
management.
●● In planning a pectoralis flap, it is important to
understand what vessels were used in cardiac
surgery (see Figure 4.5).
●● The majority of bypass patients have at
least the left and on occasion the right IMA
harvested, limiting the use of the turnover
pectoralis major muscle flap to one or
neither side.
●● If the IMA is preserved, a turnover pecto-
ralis flap is valuable as it fills the inferior
defect of the chest wound.
●● For large sternal defects, one turnover
flap is placed into the sternal defect, and
the ipsilateral pectoralis is advanced for
coverage.
●● This is also important for planning a rectus
abdominus flap for sternal coverage.
●● Anesthetic requirements:
●● Appropriate resuscitation with blood or
fluids.
●● Cardiac anesthesia if available is helpful.
●● Cardio-thoracic surgery as well as the
pump team should be in the hospital if
a cardiac emergency occurs during the
procedure.
●● Maximal paralysis is helpful during the
muscle harvest and closure.
●● Anatomy:
●● The pectoralis muscle is considered
a Mathes and Nahai type V muscle
flap with one dominant pedicle,
40  Chest wall reconstruction with pectoralis major muscle flaps

(a) (b)

(c) (d) (e)

Figure 4.3  (a) Large sternal wound following CABG after multiple debridements. Separate incisions
made for sternal insertion division. (b) Pectoralis myocutaneous advancement performed. (c) Closure
of muscle layer. (d), (e) Successful closure of large sternal wound following pectoralis myocutaneous
advancement.

the thoracoacromial artery, and several
medial perforators originating from the
IMA (Figure 4.6). The thoracoacromial
artery provides the dominant axial supply
to the pectoralis major and originates
from the second part of the axillary
artery, directly deep to the pectoralis
minor, and courses laterally to reach
the pectoralis major. This pedicle has little
variability, and the whole muscle can be
reliably raised without disrupting the
underlying pectoralis minor.
●● The origin is the sternum, anterior s­ urface of
ribs 1 through 6, and the clavicle. The inser-
tion is the bicipital groove of the proximal
humerus.
 Intraoperative details  41

(a)

(b)

Figure 4.4  Turnover flaps. Pectoralis major insertions are divided, and the muscles are based on
the secondary IMA blood supply and turned and inferiorly rotated in to fill sternal wound defects.
(a) Pectoralis major turnover flaps after dissection. (b) Flaps after inset into sternal defect.

Operative steps:
●●
1. Debridement: The indication for ­pectoralis
flaps often involves an i­ nfectious ­process;
thus, thorough debridement of any infected
or n
­ on-viable soft tissue, cartilage, or bone is
the first step of the o
­ peration. Debridement
of the wound is arguably the most ­important
element to this ­operation as one of the most
common postoperative comp­lications is con-
tinued infection and dehiscence (Figure 4.7).
a. Removal of any skin, s­ ubcutaneous tis-
sue, bone, or cartilage that is necrotic
helps achieve sternal union and wound
closure.
b. Irrigation with pulse lavage aids in
decreasing the bacterial load of the
wound (at least 3 L of saline with or
without antibiotic or dilute iodine).
c.
A rongeur and periosteal elevator
allow for debridement of the affected
­sternum and cartilage.
d. Debridement and closure are usually
done in stages, with initial deep intra-
operative cultures to guide ­long-term
antibiotics.
e. All foreign bodies, including sutures
and sternal wires, must be removed to
achieve a clean wound prior to closure.
f. Careful hemostasis must be obtained
without the use of bone wax, which
has been shown to increase the risk of
persistent osteomyelitis.
42  Chest wall reconstruction with pectoralis major muscle flaps

Figure 4.5  This patient had failed sternal

wound coverage with bilateral pectoralis major
muscle flap advancement. Patient has recurrent
­infection in the inferior portion of his wound.
The left IMA (LIMA) was used for the CABG, Figure 4.6  Pectoralis major reflected displaying
and the right IMA (RIMA) was damaged during its dominant blood supply, the thoracoacromial
debridement, so rather than a rectus abdominus artery.
flap, he will undergo a pedicled omental flap for
coverage.

2. Considering sternal fixation (Figure 4.8):

After debridement of the sternum and
costal cartilage, there often remains
a well-vascularized portion of bone
that yields the opportunity for sternal
fixation.9 If viable bone and cartilage
remain in the setting of paradoxical
chest wall movement and sternal insta-
bility, rigid sternal fixation can be a
part of chest wall r­ econstruction.10
Rigid fixation offers the benefit of acceler-
ated healing and sternal union while
­decreasing the ­i ncidence of mediastinal Figure 4.7  Example of a sternal wound that
hernia.11 requires debridement. Brown and black bone
a. Undermine the chest wall both and yellow fibrinous exudate must be removed.
superficial and deep to the pectora-
lis muscles. Preserve these muscles c.
Place bone fixation hooks on the edge
as they will be used as advancement of the sternum to allow for reduction.
flaps for sternal closure on top of the d.
Size the plates depending on rib size.
­fi xation system. e.
Place three or four plates on the ribs.
b. Identify at least three healthy ribs for f.
Use bicortical screws on the sternum
the sternal fixation system. and unicortical screws on the ribs.12
 Intraoperative details  43

(a) (b)

(c) (d)

(e) (f)

Figure 4.8  A healthy patient with sternal painful malunion following sternotomy for coronary
artery bypass graft (CABG) who underwent sternal fixation and pectoralis muscle flaps for closure.
(a) Sternal malunion; (b) identification of right rib segments; (c) identification of left rib segments.
(d) Reduction of sternal dehiscence; (e) placement of fixation system; (f) closure with bilateral
pectoralis major myocutaneous advancement flaps.
44  Chest wall reconstruction with pectoralis major muscle flaps
3. Myocutaneous advancement flaps
(see Figure 4.3):
a. Minimal subcutaneous flaps are raised
off the surface of the muscle from the
midline sternal defect.
b. The muscle is elevated off the chest wall
medial to lateral, taking care to ligate
the intercostals and i­ nternal mammary
perforators medially (Figure 4.9).
c. It is important to leave some
­perforators from the pectoralis muscle
to the overlying skin to maximize
healing potential and skin closure of
the midline and to minimize the risk of
seroma.
Figure 4.9  Harvested pectoralis m
­ yocutaneous
advancement with clamp holding pectoralis
medial border.
Figure 4.10  Elevated pectoralis major muscle with pectoralis minor muscle deep and attached to
chest wall.
d.
Care is also taken to avoid elevating
the pectoralis minor with the flap
(Figure 4.10).
e.
There is a relatively avascular
plane both superficial and deep to
the p ­ ectoralis major muscles. By
­detaching the muscle from its sternal,
rib, humeral, and medial clavicular
attachments and separating it from
the clavicular head of the deltoid,
the ­pectoralis can usually be extended
to the level of the xiphoid.
f. Lateral dissection at the insertion on
the humerus may be done until the
flaps reach midline without significant
tension. This can be done through a
separate incision near the humeral
insertion.
g. If further advancement is needed
­caudally, back cutting the superior
medial aspect of the pectoralis muscle
up to 6 cm maintains its blood supply.
h. Another option for additional mobility
involves detaching the sternocostal head
from the clavicular head of the muscle.
i. When a significant amount of
­mediastinal dead space is a problem,
bilateral flaps are usually necessary.
j. After the pectoral flaps have been
raised, suture them in the midline
with figure-of-eight sutures (strong
­monofilament such as 0-0 Prolene®;
Ethicon, Somerville, NJ).
 Intraoperative details  45

(a)   (b)

(c)

Figure 4.11  Pectoralis myocutaneous rotation advancement flap for coverage of fistula
­postesophagectomy. (a) Preoperative photograph with VAC on open wound. (b) Division of insertion
and origin of pectoralis major muscle allows it to reach to the contralateral clavicular chest and neck
region. (c) Immediate postoperative photograph following closure of wound.

k. Place drains under flaps in the midline b.

and under the bilateral subcutaneous
undermined area.
l. Suture skin closed with horizontal
mattress monofilament suture. Avoid
buried sutures.
m. Use a light compression chest binder.
4. Turnover flaps (Figure 4.4):
a. The humeral insertion must first be
divided. This can be done either by
undermining the skin superficial to the
muscle laterally over to the insertion
or by a separate incision. A separate
­incision will commonly preserve chest
skin viability.
Fold the lateral portion of the muscle
into the mediastinum while maintain-
ing its vascular supply by means of
perforators from the IMA and anterior
intercostal arteries. This maneuver may
result in a contour deformity of the
anterior chest wall, causing tension on
the skin closure. However, it nicely fills
dead space in the appropriately selected
deep sternal wound.
c.
One can also use a combination of
the turnover pectoralis flap on the
side in which the IMA has not been
harvested and a unipedicled rotational
­advancement flap on the ipsilateral side.
46  Chest wall reconstruction with pectoralis major muscle flaps
d.
The rotating end of the turnover flap
may be sutured in place at the adjacent
costal cartilage and intercostal fascia.
e.
Close and place drains as described
previously.
f.
Use a light compression chest binder.
g.
The disadvantage of the turnover flap
is that the muscle is harvested on its
non-dominant blood supply and if a
midline sternotomy is needed again,
the muscle may be damaged.
POSTOPERATIVE DETAILS
Postoperative complications are on the order of
15–20%, with the most common complications
recurrent wound infections, hematoma, wound
dehiscence, skin necrosis, or partial flap loss. The
rates of wound infection, hematoma, and seroma
are all similar at about 5%; partial flap loss is a rare
occurrence.1 Wound dehiscence and hematoma are
more common in patients with additional comor-
bidities, such as smoking, obesity, and n ­ ecessity for
anticoagulation. If medically a­cceptable, postop-
erative anticoagulation is delayed 72  hours. Drain
placement is critical in helping to avoid ­postoperative
complications. Leaving a surgical drain in until post-
operative day 22 has been shown to decrease seroma
formation from 24 to 3.5% when compared to drain
removal at day 11.2
When the thoracic cavity has been entered,
­t horacostomy tubes are recommended in the early
postoperative period to evacuate ­ postoperative
effusion and pneumothorax and are typically
­
­managed by the thoracic surgery team. Thoracic
binders are used occasionally for soft tissue com-
pression. In addition, patients are instructed to
limit range-of-motion exercises to minimize har-
vested muscle movement. If the pectoralis muscle
insertion into the humerus remains intact, then a
sling and swathe have been shown to be beneficial
to prevent muscle dehiscence.
Postoperative antibiotics are commonly used,
especially in the setting of mediastinitis or infected/
dehisced median sternotomy incisions.
NOTES
●● Pectoralis major muscle flaps are among
the most versatile and reliable flaps in
our ­armamentarium. However, the main
l­ imitation is the most inferior aspect of the
sternal wound. This area is usually under a
­considerable degree of tension. If a large defect
exists in the inferior portion, then a rectus
abdominis, latissimus dorsi, or o ­ mental flap
should be considered (see Figure 4.5).
●● If sternal fixation is required, make sure that
the wound is clean and cultures are negative
prior to hardware placement.
●● In complex cases with deep ­sternal ­mediastinitis,
it is helpful to have cardio-thoracic surgery assist
or perform the debridement.
●● Do not underestimate the critical nature of
these patients as they are usually in the ­intensive
care unit, and some may require p ­ rolonged
intubation and pressors. Occasionally, these
procedures may need to be performed while the
patients are on cardiac pressor support.
●● Some surgeons have advocated keeping ster-
nal wound flap closure patients intubated and
­paralyzed to aid in healing. This is not required,
although it is the practice of some surgeons.
●● Negative-pressure wound therapy (NPWT)
is helpful as a stable dressing in between
­debridements prior to closure. One should be
careful to place non-adherent dressings on
the mediastinal structures prior to placing the
NPWT sponge. We do not change the sponge
dressing in the intensive care unit, but typically
change this in the operating room.
CPT CODING
10180 Incision and drainage of complex
­postoperative wound infection
21627 Sternal debridement
21750 Closure of median sternotomy separation
with or without debridement
15734 Muscle, myocutaneous, or fasciocutaneous
flap; trunk
49904 Omental flap, extra-abdominal for
­reconstruction of sternal defects
REFERENCES
1. Jones G, Jurkiewicz MJ, Bostwick J, et al.
Management of the infected median
sternotomy wound with muscle flaps: the
Emory 20-year experience. Ann Surg.
1997;225:766–776.

2. Ascherman JA, Patel SM, Malhotra SM,
Smith CR. Management of ­sternal wounds
with bilateral pectoralis major ­myocutaneous
advancement flaps in 114 consecutively
treated patients: r­ efinement in technique
and outcome ­analysis. Plast Reconstr Surg.
2004;114:676–683.
3. Gummert JF, Barten MJ, Hans C, et al.
Mediastinitis and cardiac surgery—an
updated risk factor analysis in 10,373
­consecutive adult patients. Thorac
Cardiovasc Surg. 2002;50:87–91.
4. Losanoff JE, Richman BW, Jones JW.
Disruption and infection of median ster-
notomy: a comprehensive review. Eur J
Cardiothorac Surg. 2002;21:831–839.
5. Lee JC, Ramon J, Song DH. Primary ster-
nal closure with titanium plate ­fixation:
­plastic surgery effecting paradigm shift.
Plast Reconstr Surg. 2010;175(6):1720–1724.
6. Gdalevitch P, Afilalo J, Lee C. Predictors
of vacuum-assisted closure failure of
­sternotomy wounds. J Plast Reconstr
Aesthet Surg. 2010;63:180–183.
7. Rand RP, Cochran RP, Aziz S, et al.
Prospective trial of catheter irrigation and
References 47
muscle flaps for sternal wound infection.
Ann Thorac Surg. 1998;65:1046–1049.
8. Hugo NE, Sultan MR, Ascherman JA,
Patsis MC, Smith CR, Rose EA. Single
stage ­management of 74 consecutive
­s ternal wound complications with pec-
toralis major myocutaneous advance-
ment flaps. Plast Reconstr Surg.
1994;93(7):1433–1441.
9. Gottlieb LJ, Pielet RW, Karp RB, et al.
Rigid internal fixation of the sternum in
postoperative mediastinitis. Arch Surg.
1994;129:489–493.
10. Wu LC, Renucci JD, Song DH. Sternal
­nonunion: a review of current treat-
ments and a new method of rigid fixation.
Ann Plast Surg. 2005;54:55–58.
11. Cicilioni OJ, Stieg FH, Papanicolaou G.
Sternal wound reconstruction with
­transverse plate fixation. Plast Reconstr
Surg. 2005;115(5):1297–1303.
12. Chepla KJ, Salgado CJ, Tang CJ, Mardini S,
Kim-Evans K. Late complications of chest
wall reconstruction: management of pain-
ful sternal nonunion. Semin Plast Surg.
2011;25(1):98–106.
 Part     2
Breast Reconstruction

5 Breast reduction: Inferior pedicle, wise pattern 51

Tarik M. Husain and Seth R. Thaller
6 Gynecomastia 59
Devra B. Becker, Shaili Gal, and Christopher J. Salgado
7 Implant-based breast reconstruction: Tissue expander placement after mastectomy 69
Ari S. Hoschander and John Oeltjen
8 Implant-based breast reconstruction: Exchange of tissue expander for permanent implant 75
Ari S. Hoschander, Michael P. Ogilvie, and John Oeltjen
9 Breast reconstruction with abdominal flaps 79
Maurice Y. Nahabedian and Ketan M. Patel
10 Nipple reconstruction 87
Dennis C. Hammond, Elizabeth A. O’Connor, and Johanna R. Sheer
 5
Breast reduction: Inferior pedicle,
wise pattern

TARIK M. HUSAIN AND SETH R. THALLER

Introduction 51 Notes 55
Preoperative markings 52 CPT coding 56
Intraoperative details 53 References 56
Postoperative care 55

INDICATIONS

Symptomatic macromastia, including neck pain, shoulder pain, back pain, bra strap grooving, intertrigo
or skin breakdown from bra use

Table 5.1  Special equipment

Tape measure
Radiographic or wire template
Normal saline, 1-L bag with 25 mL 1% lidocaine with epinephrine 1:100,000 (tumescent)
Methylene blue and tuberculin syringe (1 mL)
IV Ancef, 1 g prior to incision, or Clindamycin, 900 mg if penicillin allergic
Blake drains 19F, 1 per side
2-0 Prolene, 2-0 Vicryl, 2-0 nylon, 3-0 Monocryl, 4-0 Monocryl sutures

INTRODUCTION of musculoskeletal complications, including neck

Macromastia is a pathologic condition consist-
ing of hypertrophy of the breast (see Figure  5.1).
It  ­generates both physical and ­psychological dis-
tress, presenting a significant threat to a ­woman’s
health-related quality of life. In addition to psycho-
logical considerations regarding poor p ­ erception
of body image and sense of self-esteem, macromas-
tia has been consistently correlated with a number
pain, back pain, headache, peripheral neuralgias,
and shoulder pain, among others. According to
data released in 2008 by the American Society
for Aesthetic Plastic Surgery (ASAPS), reduction
mammaplasty has been among the most rapidly
growing plastic surgical procedures in the United
States. More than 153,087 reductions were per-
formed in 2007, which was increased from the
1997 value of 47,874 reductions.1–4

51
52  Breast reduction: Inferior pedicle, wise pattern
(a)
Figure 5.1  Macromastia (a) anterior and (b) oblique views.
Traditionally, reduction mammaplasty has
manifested a well-established surgical approach to
the relief of physical pain and discomfort associ-
ated with breast hypertrophy. While several tech-
niques with unique advantages and disadvantages
have been proposed in the approach to breast
reduction, debate over which technique produces
optimal patient outcomes continues to persist.
In 1998, Hidalgo et al.5,6 conducted a survey at the
meeting of the American Society of Plastic and
Reconstructive Surgeons. This revealed the tradi-
tional inferior pedicle, inverted T-scar method was
the most popular reduction technique among plas-
tic surgeons (Figure 5.2). This conclusion was more
recently confirmed in 2008 when a national survey
of 2665 members of the ASPS revealed that 69% of
Figure 5.2  Inferior pedicle technique of breast
reduction.
(b)
surgeons preferred the inferior pedicle technique
over other popular methods for breast reduction.7–9
The inverted T-scar skin design, which includes
a variety of glandular pedicle types, is an attractive
alternative among reduction mammaplasty proto-
cols due to its predictability, versatility, and level of
control that it offers over both the extent of reduc-
tion and the breast-shaping process. Despite these
advantages, common criticisms of the inverted
T-scar approach include breast shape abnormalities
(pseudoptosis), areolar malposition, hypertrophic
scarring, and poor long-term projection. However,
several outcome studies have demonstrated high
patient satisfaction and well-being following reduc-
tion mammaplasty, particularly with the inferior
pedicle technique (86–97%). This tutorial p ­ resents
a method of breast reduction that is reliably repro-
ducible and consistent. Table  5.1 indicates the
­special equipment needed for this method.
PREOPERATIVE MARKINGS
1. With the patient standing, perform the mark-
ing in a preoperative hold with a chaperone
present.
2. Mark midline from the sternal notch to the
umbilicus (Figure 5.3).
3. Mark the bilateral inframammary folds (IMFs).
4. Mark the breast meridians by wrapping a tape
measure around the posterior neck and plac-
ing it in line with each nipple. Alternatively,
you can mark 7 cm lateral to the sternal notch
along the clavicular line and then reference
down to the nipple.
5. Transpose the IMFs by placing a finger under
the breast and then palpating anteriorly to feel
the point to mark along the breast meridian.

INTRAOPERATIVE DETAILS
1. Place sterile plastic adhesive drapes to square
2. Inject relevant points with methylene blue
Figure 5.3  Preoperative markings (may be drawn
with a template or freehand).
This marks the new nipple position (at the
level of the IMFs).
6. Measure 2 cm superior from this position to
place the most superior aspect of the nipple
position on the template.
7. Draw marks over the template.
8. Continue the marks laterally. Warn the
patient that all axillary and lateral chest excess
will not be removed with the index procedure,
and that this area will become more notice-
able after breast reduction.
9. Mark and discuss any asymmetries with the
patient. Warn the patient of the i­ nability to
completely correct these asymmetries.
10. Double-check the marks, including measur-
ing from the midline to relevant points using
a tape measure.
Figure 5.4  Methylene blue markings of key points.
Intraoperative details  53
off operative area.
using the tuberculin syringe (Figure 5.4).
Relevant points include the superior aspect
of the nipple along the breast meridian line,
the inferior medial and inferior lateral wing
points of the new nipple position, the inferior
medial and inferior lateral wing points of the
vertical limb, and the most lateral axillary
points on both sides. The reason for using the
methylene blue is so that the marks cannot
be erased during the process of prepping
and throughout the procedure. The marks
are critical to performing the case, as well as
for closure.10
3. Inject tumescent along incision lines and into
each breast, approximately 100 to 150 cc per
breast. Care must be taken not to over-inject
the breast, thereby creating a wet operative
field resistant to electrocautery.
4. Prep with Betadine® (Purdue Products,
Stamford, CT) (which makes it less likely
that marks are removed); if a chlorhexidine-­
resistant marking pen is used for markings,
then chlorhexidine is preferred.
5. Check that antibiotics have been given, check
placement of sequential compression devices
(SCDs), and perform a final time-out.
6. Measure the midpoint of the pedicle, which
corresponds to the breast meridian along the
IMF, which is often 12 cm from the midline.
7. Draw a “gull wing” at this point. This decreases
the rate of wound dehiscence (Figure 5.5).10
54  Breast reduction: Inferior pedicle, wise pattern

8. Mark 5 cm on either side of the gull-wing point

to indicate the width of the pedicle (10 cm total
width). This may be modified to be between
8 and 12 cm, depending on the size of the
reduction. Larger reductions may require wider
widths to decrease the rate of nipple necrosis.
9. Use a 38- or 42-mm cookie cutter, centered
over the existing nipple. The undersurface
of the cookie cutter may be marked first to
transpose the mark more easily, followed by
(a) redrawing marks.
10. Reinforce previous marks placed in the
­preoperative holding area.
11. Apply breast tourniquets by having your
assistant pinch the nipple-areolar complex and
suspend the breast toward the ceiling while you
place a lap sponge circumferentially around the
breast; tighten and hold with a Kocher clamp.
12. Incise the nipple skin circumferentially.
13. De-epithelialize all skin inferior to the nipple
with care to preserve the nipple (Figure 5.6).
14. Release the breast tourniquet as the
de-­epithelialization proceeds inferiorly
(b)
toward the IMF.
15. Complete incisions through the preoperative
Figure 5.5  (a) Gull wing; (b) 10 cm wide pedicle
(5 cm on either side of the midpoint).
markings.
16. Incise around the pedicle using Bovie
­electrocautery. Make sure not to “undercut”
the pedicle.

Figure 5.6  Standard de-epithelialization of the pedicle, followed by skin incisions and breast resec-
tion. Our skin flaps are about 1 to 1.5 cm, and we minimize superior/medial breast tissue resection
to maximize fullness in this area.

17. Start raising skin flaps superiorly toward the
clavicle. Flaps should be about 1 to 2 cm thick
and uniform. Constantly check that both sides
remain symmetric in thickness.
18. Remove breast tissue between the plane of
the skin flaps and the pedicle. You may do
this in a few relatively large piecemeal parts,
including a medial/superior/lateral breast
excision. Use of a dermatome blade attached
to a Kocher to incise the breast tissue in large
cuts has been described to decrease operative
time, but using this method takes consider-
able experience (see Figure 5.7).10
19. The least amount of breast tissue should be
removed medially to preserve superomedial
fullness for a better aesthetic result.10
20. Pay attention to meticulous hemostasis, includ-
ing the use of a DeBakey pick-up to control deep
bleeders, followed by coagulation electrocautery.
21. Half-buried horizontal suture using 2-0
Prolene® (Ethicon, Somerville, NJ) at the gull
wing. This suture starts from the outside,
just inferior to the IMF. Then, grab two bites
of dermis on each breast pillar skin (medial
and lateral), followed by suturing out the skin
inferior to the IMF adjacent to the first bite.
22. This suture should close relatively easily. If it
does not, then you may need to excise more
breast tissue.
23. Place drains, one on each side, exiting the
lateral aspect of the incision. Suture in place
with 2-0 nylon sutures.
24. Place interrupted 2-0 Vicryl® (Ethicon)
sutures into the deep dermal layer for
the ­closure’s initial shape.
Figure 5.7  Dermatome blade.
Notes 55
25. Place interrupted 3-0 Monocryl sutures into
the superficial dermal layer so that all skin
edges are touching.
26. Place running 4-0 Monocryl running
­subcuticular sutures.
27. Dermabond® (Ethicon) the incisions.
28. Once the Dermabond has dried, place
ABD (abdominal) pads or gauze over
the ­i ncisions. Place a postoperative bra
over this.
29. Admitting for overnight observation is
recommended, as is removal of drains on
postoperative day 1 if <30 cc drainage occurs
during an 8-hour shift. Encourage ambulation
on the day of surgery.
POSTOPERATIVE CARE
Patients can get the incision wet after 48 hours.
The drains are usually removed on postoperative
day 1, but if output is more than 30 mL during
an 8-hour shift, then continue them and remove
them in the clinic the following week. The
“landmark” Prolene suture should be removed
at 2 weeks postoperatively. Patients should be
deterred from exercising and raising the arms for
at least 2 weeks. Figure  5.8 shows preoperative
and postoperative images.
NOTES
Document resection weights for each breast, as
this may be important for insurance purposes.
Be  aware  of the minimum resection weight
required by the patient’s insurance.
56  Breast reduction: Inferior pedicle, wise pattern
(a)
(c)
Figure 5.8  Preoperative (a, b) and postoperative (c, d) anterior and oblique views of an inferior
pedicle technique reduction.
KEY POINTS10
●● Methylene blue allows for consistent
preoperative marks that do not fade.
●● Inframammary gull wings are associ-
ated with a considerable reduction in
wound dehiscence at the T junction.
●● Superomedial fullness leads to better
aesthetic outcomes.
●● The use of the dermatome blade may be
considered in experienced hands and has
been shown to lead to decreased opera-
tive time and decreased incidence of
postoperative seromas/hematomas.
CPT CODING
19318-50 Reduction mammoplasty
REFERENCES
1. Mandrekas AD, Zambacos GJ,
Anastasopoulos A, Hapsas DA. Reduction
mammaplasty with the inferior pedicle
(b)
(d)
technique: early and late complica-
tions in 371 patients. Br J Plast Surg.
1996;49(7):442–446.
2. Faria FS, Guthrie E, Bradbury E, Brain AN.
Psychosocial outcome and patient satisfac-
tion following breast reduction surgery.
Br J Plast Surg. 1999;52(6):448–452.
3. Mathes SJ, Schooler W. Inferior pedicle
reduction: techniques. In: Mathes SJ, ed.
Plastic Surgery. Vol. 2 Philadelphia, PA:
Saunders Elsevier; 2006.
4. Gonzalez F, Walton RL, Shafer B,
Matory WE Jr, Borah GL. Reduction
mammaplasty improves symptoms
of macromastia. Plast Reconstr Surg.
1993;91(7):1270–1276.
5. Hidalgo DA. Improving safety and aesthetic
results in inverted T scar breast reduction.
Plast Reconstr Surg. 1999;103(3):874–886;
discussion 887–879.
6. Hidalgo DA, Elliot LF, Palumbo S,
Casas L, Hammond D. Current trends in
breast reduction. Plast Reconstr Surg.
1999;104(3):806–815; quiz 816; discussion
817–818.
7. Davis GM, Ringler SL, Short K, Sherrick D,
Bengtson BP. Reduction mammaplasty:

long-term efficacy, morbidity, and
patient satisfaction. Plast Reconstr Surg.
1995;96(5):1106–1110.
8. Dabbah A, Lehman JA Jr, Parker MG,
Tantri D, Wagner DS. Reduction
­mammaplasty: an outcome analysis. Ann
Plast Surg. 1995;35(4):337–341.
9. Serletti JM, Reading G, Caldwell E,
Wray RC. Long-term patient satisfaction
References 57
f­ ollowing reduction mammoplasty.
Ann Plast Surg. 1992;28(4):363–365.
10. De Fazio MV, Fan KL, Avashia YJ et al.
Inferior pedicle breast r­ eduction:
a ­retrospective review of techni-
cal ­modifications influencing patient
safety, operative efficiency, and post-
operative outcomes. Am J Surg.
2012;204(5):e7–e14.

Gynecomastia
DEVRA B. BECKER, SHAILI GAL, AND CHRISTOPHER J. SALGADO
Introduction 59
Ultrasound-assisted liposuction 60
Special equipment 60
Preoperative markings 60
Intraoperative details 63
Postoperative care 64
CPT coding 65
Suction-assisted lipectomy 65
Special equipment 65
Preoperative markings 65
Intraoperative details 65
Postoperative care 65
Notes 65
CPT coding 65
INDICATIONS
1. Progressive gynecomastia that lasts more than
12 months and is not responsive to medical
management
2. Adolescence-associated gynecomastia that
occurs during development of social skills
and interactions and continues beyond
mid-adolescence (past 12 years of age)
INTRODUCTION
Gynecomastia is defined as benign enlarge-
ment of the breast in the male. Although this
can be physiologic and often spontaneously
regresses, it can become progressive and become
6
Direct excision using periareolar incision 65
Special equipment 65
Preoperative markings 65
Intraoperative details 66
Postoperative care 66
CPT coding 66
Free nipple graft placement in simple
mastectomy 66
Special equipment 66
Preoperative markings 66
Intraoperative details 68
Postoperative care 68
CPT coding 68
References 68
3. Weight-loss-associated gynecomastia that
persists despite massive weight loss
4. Psychologically symptomatic gynecomastia
that has associated psychological and
emotional trauma
a  factor of psychological trauma to the male
patient.  Although  the range of gynecomastia
appearance is ­ continuous and involves both
the parenchyma and the skin envelope, discrete
grades that allow for operative planning have
been developed.1,2 The Simon classification takes
59
60 Gynecomastia

Table 6.1  Simon’s classification of gynecomastia

Grade Enlargement Skin excess

I Small Absent
IIA Moderate Absent
IIB Moderate Present
III Large Present

Table 6.2  Rohrich’s classification of gynecomastia

Grade Hypertrophy Breast ptosis

I Minimal: less than 250 g of breast tissue None
II Moderate: 250–500 g of breast tissue None
III Severe: >500 g of breast tissue Grade I
IV Severe: >500 g of breast tissue Grade II or III

into consideration the degree of enlargement and
the degree of skin excess (Table 6.1).
Rohrich’s more recent 2003 classification quan-
tifies the amount of breast tissue and incorporates
ptosis, rather than skin excess, in the grading of
gynecomastia. The standard Regnault’s classifica-
tion of ptosis3 describes four types of ptosis: first
degree or grade I, in which the nipple-areolar com-
plex (NAC) is within 1 cm of the inframammary
fold; second degree or grade II, in which the NAC
is below the inframammary fold but not at the low-
est contour of the breast; third degree or grade III,
in which the NAC is at the lowest contour of the
breast; and fourth degree, or pseudoptosis, in
which the majority of the gland is below the level
of the inframammary fold.
We use Rohrich’s classification in surgical
planning (Table  6.2). The surgical goals are thus
to reduce the amount of breast tissue as well as
improve the breast ptosis while utilizing surgical
incisions that will leave inconspicuous scars. This
chapter describes ultrasound-assisted liposuction
(UAL), suction-assisted lipectomy (SAL), and tra-
ditional resection and their respective roles in the
surgical treatment of gynecomastia.
ULTRASOUND-ASSISTED
LIPOSUCTION
The UAL technique is especially useful for the more
fibrous tissue that is usually seen with gynecomas-
tia. It is effective for all grades of gynecomastia;
however, if removal of redundant skin is required,
a staged excision is delayed for 6 to 9  months
to allow for maximal skin retraction and healing
to occur. Figures 6.1 to 6.4 illustrate preoperative
and postoperative pictures of patients for whom
UAL was utilized in grade I and II gynecomastia.
Figures  6.5 and 6.6 illustrate the great flexibility
and use of UAL along with SAL.
Special equipment
Necessary equipment for UAL includes a scalpel;
an infiltration pump and infiltration cannula of
choice (we prefer a Mercedes tip cannula for infil-
tration and a solution of 1 L lactated Ringer solu-
tion mixed with 1 ampoule of 1:1000 epinephrine);
UAL generator of choice; a standard surgical aspi-
rator; and a closed-suction drain.
Preoperative markings
We perform our preoperative marking (Figure 6.7)
with the patient in the standing position, which
prevents distortion of the tissues and displacement
of the ptotic breast and skin envelope. Our mark-
ings allow visualization of critical landmarks dur-
ing the case and planning for surgical incisions.
Our sequence of marking is as follows:
1. We first mark bilateral inframammary folds.
2. Then, the sternal midline is marked.
3. The chest boundary and planned stab incision
sites are next. We design 5-mm incisions in
the lateral aspect of the inframammary fold,
 Ultrasound-assisted liposuction  61

Figure 6.1  Male with grade I gynecomastia, Figure 6.2  Six weeks postoperatively, status
­preoperative anteroposterior (AP) view. post-ultrasound-assisted liposuction and direct
excision.

(a)   (b)

Figure 6.3  (a) A 26-year-old male with grade II gynecomastia with no significant past ­medical history.
He did not take any medications. On examination, there were no testicular abnormalities. AP view.
(b) Grade I gynecomastia, lateral view preoperatively.

(a)   (b)

Figure 6.4  (a) Six-month postoperative status after UAL, SAL, and direct excision, AP view. (b) Lateral
view.
62 Gynecomastia

(a)   (b)

Figure 6.5  (a) Preoperative appearance of a 17-year-old male with grade III gynecomastia exhibiting
excessive breast volume, AP view. (b) Lateral view.

(a)   (b)

Figure 6.6  (a) Postoperative AP view reflecting a smooth chest contour after receiving UAL, SAL, and
direct excision. (b) Oblique view.

Figure 6.7  Preoperative markings of lateral sternal border, periareolar incision, and lateral inframma-
mary marks.

which provides optimal access to dense breast
parenchyma and allows access to obliterate
the inframammary fold and to suction the
medial chest.2
4. The pigmented areolar skin junction with
the non-pigmented chest wall skin, from the
3-o’clock to the 9-o’clock positions, is marked.
(This periareolar scar, used for skin incision,
camouflages the subsequent scar well.)
5. Contours and protuberant areas are marked,
particularly in the axilla, superiorly along
the upper chest, and inferiorly below the
­inframammary fold.
Intraoperative details
1. Patients receive general anesthesia and are
positioned supine with arms abducted.
2. The 5-mm lateral inframammary fold inci-
sions are made with a #15 scalpel.
3. Infiltration of wetting solution in the supra-
muscular (subcutaneous) fat layer is per-
formed first using a standard infiltration
pump and 3.0-mm cannula. For the purposes
of liposuction, subcutaneous fat is divided
into superficial, where the subdermal plexus is
located; intermediate; and deep layers. These
serve as a guideline for safe liposuction, as
suctioning in the intermediate and deep layers
prevents vascular compromise and contour
irregularities.4 A “superwet” technique, with
Figure 6.8  Infiltration of wetting solution.
Ultrasound-assisted liposuction  63
a 1:1 ratio of infiltrate to estimated aspirate,
is used with the solution described previ-
ously, 1 L lactated Ringer solution mixed with
1 ampoule of 1:1000 epinephrine. This helps to
improve hydrodissection as well as to improve
hemostasis and creates a low-density medium
through which the ultrasound waves can
travel (Figure 6.8).
4. UAL is performed with an ultrasound genera-
tor machine, a 3.8-mm probe, and a standard
surgical aspirator for evacuation. A probe is
used rather than a cannula because the probe
has the advantage; it imparts more focal
ultrasonic energy per amplitude than hollow
probes and cannulas, which results in more
efficient fat emulsification. The subdermal
fat can be more easily approached, which
allows for a better contour and stimulates
skin ­contraction.5 The size of the cannula
­correlates with the depth of fat removal,
and smaller cannulas should be used for more
superficial deposits and final contouring.
5. Routine intraoperative skin protection
consists of a plastic port inserted in the
­incision (through which the ultrasonic probe
was passed), a wet towel, continuous saline
­irrigation (40 mL/hour), a probe sheath,
and use of continuous probe movements
(Figure 6.9). Intraoperative skin protection is
necessary with UAL because the ultrasound
probe becomes hot and can leave skin burns.
64 Gynecomastia
Figure 6.9  Ultrasound probe with plastic port used for skin protection.
6. A feathering technique is utilized and does
not require pre-tunneling (as opposed to
SAL).
7. Individual early probe passes (“stroke
­technique”) consist of continuous, deliberate
passes of the cannula through the intermedi-
ate fat layer in a radial fashion from the lateral
inframammary fold incisions.
8. Late probe passes should concentrate in the
subareolar region where most of the fibrocon-
nective tissue is located.
9. A bimanual technique is used with the non-
dominant hand guiding the UAL cannula
through the subdermal layer. This addresses
the dense fibrous tissue of gynecomastia and
allows for maximal skin retraction.
10. The periphery is treated for final c­ ontouring.
Disruption of the inframammary fold is
essential for achieving a more gradual transi-
tion of the breast to the abdomen, which is
characteristic in men.2
11. The adherent zone, in the upper outer quad-
rant as the breast retreats into the axillary
tissue, should be suctioned minimally, if
at all. Adherent zones exist where there is
minimal-to-no deep fat layer and the super-
ficial layer and its overlying dermis are thin.
These zones are more susceptible to contour
deformities.4 In the upper outer quadrant, the
superficial subcutaneous plane is adherent to
the underlying muscle fascia. Thus, this area
should be suctioned only for contouring, and
extreme caution should be exercised.2
12. Once the application of ultrasound is com-
plete, evacuation of emulsified fat and final
contouring are performed with a Mercedes tip
liposuction cannula.
1 3. After evacuation is complete, a closed-suction
drain is placed within the chest and secured
to the skin; incisions are closed in a two-
layer closure, and Dermabond® (Ethicon,
Somerville, NJ) is applied.
Postoperative care
A patient can be sent home the same day of surgery
if medically stable and they meet discharge criteria.
The patient must be alert and oriented. Vital signs
should be within normal limits. There should not be
any excess bleeding or drainage or any emesis, and
unassisted ambulation is necessary. An adult must
be available to escort the patient home. A ­compressive
vest is to be worn by the patient for 4 weeks during
the day and night, followed by 4 weeks during the
night only. The patient may remove the compressive
vest for showering, which is usually allowed within
48 hours after surgery.
Patients should begin ambulating on the day
of surgery. Physical activity should be low for the
first week and should gradually increase after that;

patients should return to full activity at 4 to 6 weeks
after surgery. There should be no heavy lifting (no
greater than 10 pounds) for 8 weeks. Drains are
removed once output is less than 30 mL/day.
CPT coding
15877 UAL alone, SAL, trunk (2013 CPT)
SUCTION-ASSISTED LIPECTOMY
Suction-assisted lipectomy can be useful if breast
tissue is not dense and consists primarily of fatty
tissue. Although it can be used for dense, fibrous
breasts, the procedure is more technically chal-
lenging, and surgical results may not be as good
as with UAL.
Special equipment
Necessary equipment for SAL includes scalpel,
a suction source and tubing, tumescent solution
(as described previously), and liposuction cannulas.
Preoperative markings
Preoperative markings are the same as for UAL.
Intraoperative details
1. Patients receive general anesthesia and are
positioned supine with arms abducted.
2. Small stab incisions are made with a #15
­scalpel, and tumescent fluid is added to the
breast similar to the ultrasound-assisted
approach. Typically, 1 L of fluid is infiltrated
in the supramuscular layer of each breast until
tissue consistency is firm by manual palpation.
3. Using a Mercedes tip cannula, standard
liposuction with pretunneling and feathering
is performed, evenly removing tissue from
the area of concern. Particular attention is
directed in the subareolar area, where the
more fibrous fat is located.
4. Note is made of the amount of tumescent fluid
instilled and the amount of liposuction aspirate
removed from each side to ensure symmetry.
5. Closed-suction drains are placed and inci-
sions are closed in a two-layer fashion and
dressed with Dermabond.
Direct excision using periareolar incision  65
Postoperative care
Postoperative care is the same as for UAL.
Notes
Following UAL or SAL, a subareolar resection
may still be needed to reduce the fibrous t­issue
beneath the areola. This can be performed at
the initial operation or at a later time in a staged
fashion. In addition, skin resection may be neces-
sary at a later date if the skin has not tightened
sufficiently.
CPT coding
15877, SAL, trunk (2013 CPT)
DIRECT EXCISION USING
PERIAREOLAR INCISION
The direct excision using a periareolar incision
technique is especially useful in the patient with a
well-circumscribed and isolated mass of fibrous tis-
sue under the areola. These patients are usually fit,
otherwise have a trim physique, and have little sur-
rounding stromal or fatty overgrowth. It is also use-
ful in cases of failure of previous liposuction and can
be used when liposuction equipment is not available.
Special equipment
Necessary equipment includes a scalpel, 1% lido-
caine with epinephrine, retractors (both small,
such as a Sen retractor, and larger, such as a Rich or
Army-Navy retractor), and electrocautery.
Preoperative markings
1. Bilateral inframammary folds are marked first.
2. The sternal midline is indicated.
3. Then, the chest boundary is marked.
4. The pigmented areolar skin junction with
the non-pigmented chest wall skin, from the
3-o’clock to the 9-o’clock positions, is delin-
eated. In larger breasts, this incision can be
extended medially or laterally.
5. Contours and protuberant areas are marked,
particularly in the axilla, superiorly along
the upper chest, and inferiorly below the
­inframammary fold.
66 Gynecomastia

Intraoperative details Postoperative care

1. The procedure can be performed under local
anesthesia, intravenous sedation, or general
anesthesia. General anesthesia is preferred at
our institution.
2. The marked incision and surrounding chest
flaps are infiltrated with a dilute solution of
lidocaine with epinephrine.
3. A #15 scalpel is used to incise along the lower
border of the areola at the junction of the pig-
mented areolar skin with the non-pigmented
skin of the lower breast.
4. Around the inferior lower half of the breast,
the fibrous tissue is dissected free from the
surrounding breast flaps until the limits of the
fibrous mass that were marked preoperatively
are reached (Figure 6.10).
5. Every effort should be made to leave the fat
associated with the flaps behind, as this will
protect against creating a central depres-
sion deformity after removal of the cen-
tral fibrous component. Under the areola,
5–10 mm of evenly layered fibrous tissue
should be left to help prevent this central
depression.6
6. Tissue resection is beveled peripherally to
also help develop smooth contours in all
directions.7 Hemostasis is obtained, and the
incision is closed in a two-layered fashion;
Dermabond is applied.8 A compressive vest is
placed.
Immediate postoperative care is the same as for
UAL. A support vest can help ensure that the are-
ola and chest wall flaps lay smoothly against the
underlying muscle during the first week of healing.
CPT coding
19300 direct excision using a periareolar incision,
mastectomy for gynecomastia (2013 CPT)
FREE NIPPLE GRAFT PLACEMENT
IN SIMPLE MASTECTOMY
The procedure for free nipple graft placement in
simple mastectomy is applicable to a small group
of patients with gynecomastia including either
those with massive weight loss with excessive skin
laxity  and glandular tissue or those undergoing
female-to-male transsexual ­operations. Figures 6.11
and 6.12 d­ emonstrate results from this operation.
Special equipment
Necessary equipment includes a bolster dressing
made of xeroform gauze, mineral oil–soaked ­cotton
balls or Jones cotton, and nylon sutures.
Preoperative markings
We use the ratios of Murphy et al. (Table 6.3) to
mark the position of the NAC.8 Initial reference

Figure 6.10  Direct excision of fibrous tissue underneath the areola using the periareolar direct
­excision technique.
 Free nipple graft placement in simple mastectomy  67

(a)
(a)

(b) (b)

(c)
Figure 6.11  (a)–(c) Preoperative appearance of
male with grade IV gynecomastia so severe he
required free-nipple grafts.
(c)
Figure 6.12  (a)–(c) Postoperative appearance
after free-nipple grafts and mastectomy via
inframmamary approach.

Table 6.3  Ratios to mark the nipple-areolar complex position

Ratio Anatomic landmarks Mean ratio

1 (nipple plane) Sternal notch to pubis 0.33 × distance of sternal notch to pubis
2 (internipple distance) Chest circumference 0.23 × chest circumference
Note: Average distance of sternal notch to nipple = 21 cm.
68 Gynecomastia
measurements, taken with the patient in the stand-
ing position, are sternal notch to pubis (in centi­
meters) and chest circumference (in centimeters).
Ratio 1 = Sternal notch to nipple plane/­
suprasternal notch to pubis = mean = 0.33
Ratio 2 = Internipple distance/chest c­ ircumference
= mean = 0.23
Sternal notch to nipple = 21 cm
Measurement of chest circumference
Measurement of sternal notch to pubis
The bilateral inframmamary fold, sternal mid-
line, and chest boundary are marked as usual.
Intraoperative details
1. After general anesthesia is induced and the
patient is prepped and draped, the areola is
measured at 2.8 cm (found to be the mean
areolar diameter) and is harvested as a full-
thickness skin graft.
2. Through an inframammary incision, a flap is
raised in the subcutaneous plane anterior to
the breast parenchyma.
3. The breast tissue is excised, the excess skin
is trimmed, and the incision is closed in a
standard two-layer fashion after closed-suction
drains are placed.
4. The nipple placement site is established using
the previously calculated ratios.
5. As described by Murphy et al.,8 the preop-
erative measurement of the sternal notch to
pubis is multiplied by 0.33 to establish the
nipple plane. Once this nipple plane (x axis) is
defined, the internipple distance is calculated
by multiplying ratio 2 by the preoperatively
determined chest circumference. This leads to
nipple placement about 21 cm from the supra-
sternal notch.
6. Nipples are applied as full-thickness grafts
with a tie-over bolster dressing.
Postoperative care
The patient can be discharged within 24 hours if
medically stable. We remove the bolster dressing at
1 week.
CPT coding
19350 free nipple graft, nipple/areola reconstruc-
tion (2013 CPT). This is coded in addition to
19300, simple mastectomy, if the mastecomy is
performed.
REFERENCES
1. Simon BE, Hoffman S, Kahn S. Classification
and surgical correction of gynecomastia.
Plast Reconstr Surg. 1973;51(1):48–52.
2. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr.
Classification and management of gyne-
comastia: defining the role of ultrasound-
assisted liposuction. Plast Reconstr Surg.
2003;111(2):909–923.
3. Regnault, P. Breast ptosis. Definition and
treatment. Clin Plast Surg. 1976;3(2):193–203.
4. Warren RJ, Neligan PC, eds. Plastic Surgery:
Volume 2: Aesthetic Surgery. London, UK:
Elsevier Health Sciences; 2012.
5. Hodgson EL, Fruhstorfer BH, Malata CM.
Ultrasonic liposuction in the treatment
of gynecomastia. Plast Reconstr Surg.
2005;116(2):646–653; discussion 654–655.
6. Hammond DC. Surgical correction of
gynecomastia. Plast Reconstr Surg.
2009;124(1 Suppl):61e–68e.
7. Hammond DC. Atlas of Aesthetic Breast
Surgery. London, UK: Saunders Elsevier;
2009.
8. Murphy TP, Ehrlichman RJ, Seckel BR. Nipple
placement in simple mastectomy with free
nipple grafting for severe gynecomastia.
Plast Reconstr Surg. 1994;94(6):818–823.
 7
Implant-based breast reconstruction:
Tissue expander placement after
mastectomy

ARI S. HOSCHANDER AND JOHN OELTJEN

Introduction 70 Note 73
Preoperative markings 70 CPT coding 73
Intraoperative details 70 References 73
Postoperative care 73 Acknowledgment 73

INDICATIONS

1. Desire for breast reconstruction after 2. Lack of adequate breast skin envelope tissue
mastectomy for immediate placement of permanent
implant

Table 7.1  Special equipment

AlloDerm®, 6 × 16 or 8 × 16 cm thick
Antibiotic irrigation solution comprised of
• NS 500 mL
• Ancef 1 g
• Gentamicin 80 mg
• Bacitracin 50,000 units
Warm saline bath not to exceed 37°C
Ancef 1–2 g IV and vancomycin 1 g IV given prior to mastectomy incision
Blake drains, 19F, two per side
Tissue expanders (author preference is low-profile, integrated port type)
Sterile antiseptic skin preparation
BioPatch® antibiotic-impregnated dressings for Blake drains

69
70  Implant-based breast reconstruction: Tissue expander placement after mastectomy
INTRODUCTION
Breast reconstruction after mastectomy can be
both challenging and rewarding. It offers the
patient a sense of femininity and beauty following
this disfiguring procedure. The immediate place-
ment of tissue expanders after mastectomy is the
most popular American method for breast recon-
struction. The eventual results are pleasing from
both an aesthetic and a reconstructive standpoint.
The technique described in this chapter utilizes
AlloDerm Acellular Dermal Matrix (LifeCell™,
Branchburg, NJ) (Table 7.1) as we believe that its
use allows for the creation of natural breast mound
ptosis in the reconstruction. Variations of this tech-
nique have evolved since their original description
in the ­literature more than 8 years ago.1
PREOPERATIVE MARKINGS
1. Midline from sternal notch to umbilicus.
2. Bilateral inframammary folds (IMFs).
3. Measure the approximate base diameter for
tissue expander size estimate.
4. Optional marking of circum-areolar “key-
hole” or ellipse for the general surgeon to use
as a skin-sparing mastectomy incision.
INTRAOPERATIVE DETAILS
1. Irrigate copiously with warm normal saline (NS).
2. Inspect for and achieve hemostasis multiple
times.
Figure 7.1  Identification of the inferior margin of the pectoralis muscle requiring release.
3. Redrape with clean towels and remove all
instruments and equipment used during
mastectomy.
4. Begin soaking AlloDerm in a warm saline
bath. AlloDerm is ready to use when soft
and pliable throughout. This may take
10–40 ­minutes depending on thickness.
5. Identify the pectoralis major muscle and
release the inferolateral margin of this muscle
up to the 3-o’clock position on the right and
the 9-o’clock position on the left (Figure 7.1).
6. Elevate the pectoralis major muscle off the
ribs, intercostal muscles, and pectoralis minor
muscle lateral to medial using Bovie electro-
cautery. Leave the sternal attachment above
the 3- and 9-o’clock positions intact on the
right and left chest, respectively.
7. Incise the inferior margin of the pectoralis
major off the ribs, making sure to leave a cuff
of fascia at the inferior margin.
8. Transpose a mark of the IMF onto the chest
wall by inserting a 25-gauge needle through
the skin along the previously marked IMF.
Use a sterile marking pen to mark the fold
directly onto the chest wall (Figure 7.2).
9. Place the AlloDerm onto the chest wall and
excise a small area of its inferomedial corner
for a more rounded sling. Proper orientation
of the AlloDerm is imperative. It has two
surfaces: dermal and basement membrane.
These can be distinguished by their physi-
cal p
­ roperties. The dermal surface is smooth
and shiny and absorbs blood; the basement

membrane surface is rough and dull and
repels blood. The dermal surface should
always be oriented toward the more vascular-
ized tissue. In this case, the dermal surface
(smooth and shiny) should face the underside
of the skin flap, and the basement membrane
surface should contact the tissue expander.
10. Suture the superomedial corner of the
AlloDerm to the inferomedial corner of
the pectoralis major muscle in a horizontal
­mattress fashion using 2-0 PDS (polydioxa-
none) suture.
1 1. Run this suture caudally along the medial
­border of the AlloDerm, tacking it to the peri-
osteum or pericondrium of the underlying ribs.
12. Continue this suture along the inferior border
of the AlloDerm, now taking purchase first
of the remnant of Scarpa’s fascia at the IMF,
then the AlloDerm, then the underlying peri-
osteum along the mark that was previously
drawn on the chest wall as the transposed
IMF. Be sure to keep the fascial sutures from
causing skin dimpling at the external IMF.
Run this suture laterally along the transposed
Figure 7.2  Internal marking of the IMF.
Intraoperative details  71
IMF and then cranially at the lateral b ­ order
of the AlloDerm. Now, the AlloDerm is
tacked down on three sides. (Purchase of
Scarpa’s f­ ascia is only taken along the infero-
medial aspect of the IMF, stopping at the
mid-­clavicular line.)
13. Next, place a 2-0 PDS suture from the
superomedial corner of the AlloDerm to the
inferomedial corner of the pectoralis major
muscle and run this suture laterally, attach-
ing AlloDerm to the fascial extension of
the p
­ ectoralis major. This suture can be run
midway to the end of the AlloDerm, and the
suture can be protected and left attached at
this point (Figure 7.3).
14. Now, measure the base width of the pocket.
Selection of the tissue expander is based on
this measurement.
1 5. Copiously irrigate the pocket with warm NS.
16. Place one drain into the pocket posterior to
the AlloDerm along the IMF. Place the other
drain anterior to the pectoralis muscle and
tracking superiorly, then medially, and then
down the medial border of the pectoralis
Figure 7.3  AlloDerm placement and suturing to
the pectoralis major muscle and the chest wall
at the IMF.
72  Implant-based breast reconstruction: Tissue expander placement after mastectomy
major muscle. These drains should exit the
skin inferior and lateral to the IMF at the
anterior axillary line. Secure to the skin with
3-0 nylon sutures.
17. Irrigate the pocket first with copious amounts
of NS to remove fat and debris. Then i­ rrigate
with the antibiotic irrigation solution
described previously and allow this solution
to sit in the pocket until the implant is placed.
18. Re-prep the skin with sterile antiseptic skin
preparation solution and re-towel the area.
1 9. Change gloves.
20. Irrigate the expander in antibiotic irrigation
solution.
21. Prepare the expander first by aspirating all air
from the implant.
22. Inject 120 mL sterile injectable saline into the
expander.
Figure 7.4  Final position and placement of the AlloDerm.
23. Place the implant under the pectoralis major
and AlloDerm. Use caution so the implant
does not contact the skin.
24. Continue the suture that was started and pro-
tected from the medial to the lateral margin
of the AlloDerm and pectoralis major muscle
(Figure 7.4).
25. Now, the implant can be inflated in vivo
to an appropriate size that does not place
tension on the pocket or the overlying
skin but fills the implant as much as pos-
sible to ­prevent “dead space” for seroma
collection.
26. Prior to closure of the skin, the incisional
edges are sharply debrided of 1–2 mm of
­divitalized skin that was traumatized by
retraction during the mastectomy.

27. The skin is then closed with 3-0 PDS suture
in a deep dermal layer and a running 4-0
Monocryl® (Ethicon, Somerville, NJ) in the
subcuticular layer.
28. Dermabond® (Ethicon) is applied to the inci-
sions, and the drain sites are dressed with
BioPatches® (Ethicon) held in place with a
semi-occlusive adherent dressing.
29. Finally, abdominal (ABD) pads and a surgical
brassiere are placed. Care is taken to keep the
brassiere snug but loose fitting. Compression
could compromise the skin flap.
POSTOPERATIVE CARE
Patients can be sent home within 24 hours if
medically able. Oral antibiotics are continued for
48  hours.2 Drains are left in place until output is
less than 30 mL in 24 hours or at 3 weeks postop-
eratively, whichever occurs first. Patients should
be deterred from exercising and arm-raising for at
least 3 weeks.
Begin inflating the expander at 2 weeks if the
mastectomy incision appears to be healing well. The
port can be found using the magnetic port l­ocator
provided by the company and then injecting per
the manufacturer’s instructions. The expander can
tolerate expansion up to 150 mL  at  a  time; how-
ever, expansion should be stopped when the patient
feels pressure or the mastectomy flaps appear
Acknowledgment 73
blanched. It is of utmost importance to main-
tain strict sterile precautions when expanding the
implant.
NOTE
Intraoperative and postoperative sterility must be
adhered to at all times.
CPT CODING
19357 Immediate insertion of prosthesis
15777 Acellular dermal matrix
REFERENCES
1. Breuing KH, Warren SM. Immediate bilat-
eral breast reconstruction with implants
and inferolateral AlloDerm slings. Ann Plast
Surg. 2005;55(3):232–239.
2. Avashia YJ, Mohan R, Berhane C,
Oeltjen JC. Postoperative antibiotic
­prophylaxis for implant-based breast
­reconstruction with acellular dermal matrix.
Plast Reconstr Surg. 2013;131(3):453–461.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of Elan
Horesh.
 8
Implant-based breast reconstruction:
Exchange of tissue expander for
permanent implant

ARI S. HOSCHANDER, MICHAEL P. OGILVIE, AND JOHN OELTJEN

Introduction 76 Notes 78
Preoperative markings 76 CPT coding 78
Intraoperative details 76 Reference 78
Postoperative care 78

INDICATION

Permanent implant replacement after use of tissue expanders for immediate reconstruction

Table 8.1  Special equipment

Antibiotic irrigation solution with
• Normal saline 500 mL
• Ancef, 1 g
• Gentamicin, 80 mg
• Bacitracin, 50,000 units
Ancef 1–2 g IV and vancomycin 1 g IV given prior to incision
Long-tip Bovie
Lighted retractor
Implant sizers
Permanent breast implantsa
Sterile antiseptic skin preparation
a Multiple successive sizes should be selected based on the base width of
the chest and beginning with the volume currently in the expander.
Usually, a volume of 25% more than the current expansion will be needed.

75
76  Implant-based breast reconstruction: Exchange of tissue expander for permanent implant

INTRODUCTION displaced from lying directly under the skin

incision (Figure 8.2).
There are many options available to the plastic 3. Bovie down to previously placed expander
­surgeon and patient considering breast reconstruc- and open pocket in a longitudinal fashion
tion after mastectomy. As expressed in the previous (Figure 8.3).
chapter, implant-based reconstruction is a viable
option that has produced excellent results from
both an aesthetic and a reconstructive ­standpoint.1
Although some surgeons prefer immediate recon-
struction with permanent implants, the prevailing
trend is to place temporary tissue expanders first,
followed by expansion and then a second operation
exchanging the t­issue expander for a permanent
implant. The choice of delayed versus immediate
reconstruction is based on multiple factors and is
not addressed in this chapter. Table  8.1 indicates
special equipment needed.

PREOPERATIVE MARKINGS
1. Midline from sternal notch to umbilicus
2. Bilateral inframammary folds (IMFs)
3. Measure approximate base diameter for
­permanent implant size estimation (Figure 8.1)

INTRAOPERATIVE DETAILS
1. Open previous skin incisions with scalpel and
electrocautery.
2. Raise the inferior mastectomy flap in a
stair-step fashion, being sure to dissect a
few millimeters in the subcutaneous plane
­inferiorly. This will place the incision through Figure 8.2  Stair-step method.
the AlloDerm® (LifeCell™, Branchburg, NJ),

Figure 8.3  Tissue expander beneath incised

Figure 8.1  Preoperative markings. capsule/AlloDerm.

4. Release expander adhesions with a finger
sweep.
5. Puncture the tissue expander to release fluid.
Keep the Yankauer suction directly above
the puncture site to suction fluid from the
expander as it is punctured. Remove the
expander.
6. Copiously irrigate the pocket with normal
saline.
7. A capsulotomy (possible capsulectomy) will
be required at this point. Using a long-tip
bovie and lighted retractor, the capsule is
released superiorly in the subpectoral plane.
It is best to start this capsulotomy superome-
dially directly overlying a rib; this will help
avoid entering the intercostal space. The dis-
section begins in an avascular plane beneath
the undersurface of the pectoralis major.
(a)
(b)
Figure 8.4  Capsulotomy marking (a) and incision (b). Note the pectoralis minor muscle still attached
to the chest wall.
Intraoperative details  77
Now, the dissection continues in this ­relatively
avascular plane laterally toward the pecto-
ralis minor. Care is taken to stay superficial
to the pectoralis minor. The superior release
is approximately 180° from the medial-most
to lateral-most aspect of the implant pocket
to fully open the superior pole (Figure 8.4).
Additional vertical scoring of the anterior
capsule at the level of the horizontal inci-
sion can also be performed. Inferiorly, if the
capsule is too tight, it may be released on the
undersurface of the AlloDerm. If a complete
capsulectomy is performed, consideration
should be given to the placement of 19F Blake
drains.
8. A temporary sizer is placed; it is approxi-
mately 125% of the expanded volume of the
tissue expander. Retained air is ­w ithdrawn
78  Implant-based breast reconstruction: Exchange of tissue expander for permanent implant
using a 60-mL syringe, and then normal
saline is injected until the desired size
is obtained. Temporary skin closure is
­performed with interrupted 3-0 Vicryl®
(Ethicon, Somerville, NJ) sutures in ­layers,
making sure to close both the capsule and
skin as both will directly affect the final shape
achieved. At this point, symmetry on the con-
tralateral breast should be assessed with the
patient in an upright sitting position.
9. Once the size of the permanent implant
has been decided, the temporary sutures
and implant sizer are removed; the pocket
is copiously irrigated with normal saline,
and hemostasis is ensured. This is followed
by irrigation with the antibiotic solution
detailed previously.
10. The skin is prepped again with s­ terile
­a ntiseptic solution. Gloves should be
changed at this point and the operative field
isolated with towels to maintain aseptic
technique.
11. 3-0 Vicryl interrupted sutures are placed
at the free edges of the capsule but are left
untied, for eventual capsule closure. Sutures
should be placed close enough together to
obtain a w­ atertight seal. Knots should not be
buried as they must lie outside the capsule and
away from the implant.
12. The permanent implant (saline or silicone)
should be prepared and placed in the usual
fashion using aseptic technique.
13. Once the permanent implant is in place, the
previously placed 3-0 Vicryl sutures are tied
to the close the capsule around the newly
placed implant.
14. The skin is then closed with 3-0 Monocryl
suture in a deep dermal layer and a running
4-0 Monocryl suture in the s­ ubcuticular layer.
1 5. Dermabond is applied to the incision.
16. Abdominal (ABD) pads and a surgical
­brassiere are placed. Care is taken to keep the
brassiere snug but not too tight. Compression
could compromise the skin flaps.
POSTOPERATIVE CARE
Patients can be sent home after a short stay in the
post anesthesia recovery unit, if medically able.
Postoperative oral antibiotics are not necessary.
Patients should be deterred from exercising or rais-
ing their arms above their head for at least 2 weeks.
NOTES
Adherence to intra- and postoperative sterility is
paramount for short- and long-term success.
CPT CODING
19357 Immediate insertion of prosthesis
REFERENCE
1. Breuing KH, Warren SM. Immediate ­bilateral
breast reconstruction with implants and
inferolateral AlloDerm slings. Ann Plast Surg.
2005;55(3):232–239.

Breast reconstruction with
abdominal flaps
MAURICE Y. NAHABEDIAN AND KETAN M. PATEL
Introduction 80
Preoperative markings 80
Breast markings 80
Abdominal markings 80
Intraoperative details 80
Free MS-TRAM/DIEP/SIEA flaps:
Common pathway 80
SIEA pathway 81
MS free TRAM or DIEP pathway 81
DIEP pathway 81
INDICATIONS
1. Patients desiring autologous reconstruction
2. Patients with past history of radiation therapy
3. In patients following failed implant
reconstruction
Table 9.1  Special equipment
Handheld Doppler
Microscope and/or high-power loupes (>4×)
8-0 or 9-0 nylon suture
Microsurgical instrument tray
Soft polypropylene mesh
Vessel loupes
Medium and small vascular clip appliers
Microclips
Micro bipolar cautery
3000–5000 units of IV heparin prior to flap division
9
MS free TRAM pathway 82
Recipient vessel selection 82
Microsurgical anastomosis 83
Pedicled TRAM flap 83
Recipient site closure 84
Donor site closure 84
Postoperative details 84
CPT coding 85
References 85
4. In patients who desire an “abdominoplasty”
appearance
Microvascular clamps
Sutures include: 3-0/4-0 Monocryl, 2-0 PDS,
0-Prolene® (Ethicon)
15-F drains
Wide-mouth rongeur
Thoracic set for internal mammary exposure
Freer elevator
Heparinized saline
Electrocautery unit
Short and long tenotomy scissors
79
80  Breast reconstruction with abdominal flaps
INTRODUCTION
Abdominal flap-based breast reconstruction
remains a popular choice among patients seek-
ing autologous breast reconstruction. This is
primarily because the abdomen is often an excel-
lent donor site, with a postoperative appear-
ance resembling that of an a­bdominoplasty.
Preservation of form and function is r­eadily
achieved using modern techniques of flap har-
vesting. The traditional transverse rectus abdom-
inis myocutaneous (TRAM) flap requires the use
of most, if not all, of the rectus abdominis muscle
and has the potential disadvantage of abdominal
weakness or abnormal contour abnormalities.
With the advent of muscle preservation, donor
site morbidities have been minimized using the
muscle-sparing (MS) free TRAM, deep inferior
epigastric perforator (DIEP), and s­ uperficial infe-
rior epigastric artery (SIEA) flaps. These flaps,
however, require e­ xpertise in microvascular tech-
niques and thus are used o ­ ccasionally based on
national statistics. Table  9.1 indicates the equip-
ment needed.
PREOPERATIVE MARKINGS
Breast markings
1. Superior extent of the breast is marked.
2. Inframammary fold is marked.
3. Midline is marked.
4. Lateral mammary fold is marked.
5. The mastectomy incisions are delineated
(skin or NS pattern).
Abdominal markings
1. With the patient standing, the abdominal
midline is delineated from the xiphoid pro-
cess to the pubic bone. The anterior superior
iliac spine (ASIS) is palpated and delineated
bilaterally. The proposed upper border of
the flap is delineated. This definitive line is
marked at the level just above the umbilicus.
The inferior extent of the flap is marked via
a curvilinear line extending from the ASIS
toward the pubic symphysis. This line is
tentative and is not definitively decided on
until the patient is in the operating room
(Figure 9.1).
Figure 9.1  The superior marked line extends
horizontally just above the level of the umbilicus
toward the ASIS. The inferior line is marked from
the ASIS to the pubic symphysis in a curvilinear
direction.
2. Observation for an abdominal hernia or dias-
tasis is important, as the recti muscles will be
slightly laterally displaced.
3. Handheld Doppler verification in the
­peri-umbilical area is sometimes useful
and can isolate the location of potential
perforators.
INTRAOPERATIVE DETAILS
Free MS-TRAM/DIEP/SIEA flaps:
Common pathway
1. The approach to the patient desiring free-tissue
transfer is considerably different from that for a
pedicled transfer. Therefore, a pedicled abdom-
inal flap is discussed in a different section.
2. The superior incision is initially made down
to the level of the anterior rectus sheath.
This plane is dissected superiorly using
­electrocautery to the level of the xiphoid
­process and costal margin.
3. The patient is flexed approximately 30°, and
the undermined upper abdominal flap is
transposed over the lower abdominal pannus
to confirm the position of the inferior incision.
This maneuver will ensure that the abdomen
will be able to be closed.
4. Once confirmed, the entire ellipse is incised
using electrocautery to the level of the anterior
rectus sheath.

5. If the SIEA and vein are visualized and of
appropriate caliber, an SIEA flap can be
­considered. These vessels are usually located in
the paramedian region of the inferior incision.
SIEA pathway
Dissection of the vessels in the SIEA pathway is
performed using a combination of sharp and blunt
instruments. Once sufficient length is achieved,
the flap is ready for harvest.
MS free TRAM or DIEP pathway
1. If the SIEA flap is not possible because the
vessels are absent or inadequate, the MS free
TRAM or DIEP flap algorithm is followed.
2. A circumferential incision around the
­umbilicus is made, and the umbilicus is pre-
served on its stalk.
3. The initial dissection proceeds lateral to medial,
extending to the linea semilunaris. Medial to
the linea semilunaris requires careful dissection
using either low-energy monopolar cautery or
bipolar cautery to look for the perforating ves-
sels from the deep inferior epigastric system.
4. At this point, a critical decision is made regard-
ing the MS free TRAM or the DIEP flap. If the
patient’s body habitus permits and the presence
of a dominant perforator with a palpable pulse
is verified, a DIEP flap dissection is performed
(Figure 9.2).
Figure 9.2  A large, single perforator is ­identified.
Pulse palpation and Doppler verification of
strong arterial and venous signals are necessary
prior to single-perforator DIEP flap elevation.
Intraoperative details  81
DIEP pathway
1. An anterior sheath fasciotomy is p ­ erformed
slightly superior and predominantly
­i nferior to the perforator. This is performed
using low-level electrocautery or scissors.
Perforator dissection then proceeds in the
caudal direction.
2 . Bipolar or low-current monopolar cautery
is used for perforator dissection. Our pre-
ferred technique is to use a blunt Weitlaner
­retractor and a fine-tip Jacobsen m ­ osquito
clamp to separate the perforator and
­u nderlying source vessel from the muscle
fibers. Care is taken to avoid thermal injury
to the main pedicle, and judicious use of clips
for side-branching v­ essels can help prevent
injury. It is also important to preserve the
lateral innervation to the rectus abdominis
muscle.
3. Once the pedicle is visualized on the underside
of the rectus abdominis muscle, the proximal
dissection is facilitated and can proceed using
clips along the large-caliber side branches
(Figure 9.3).
4. Pedicle dissection usually proceeds to the
point where the venae commitans become
one vein and is usually 1–2 cm distal to the
external iliac vessels. This will ensure adequate
pedicle length and vessel caliber. At this point,
the DIEP flap is ready for harvest.
Figure 9.3  Careful intramuscular dissection will
allow for maximal muscle preservation while
­performing the proximal pedicle dissection.
82  Breast reconstruction with abdominal flaps
MS free TRAM pathway
1. When body habitus is large or the perforator
anatomy is deemed inadequate, a MS-TRAM
flap is generally preferred.
2. Typically, an island of perforators is delineated
on the anterior rectus sheath. The fascial island
is incised and elevated off the surface of the
rectus abdominis muscle. The undersurface of
the rectus abdominis is freed, and the course of
the inferior epigastric artery and vein is visual-
ized or palpated (Figure 9.4).
3. The rectus abdominis muscle is harvested using
a fine-tip Jacobsen clamp and electrocautery.
It is essential to be aware of the course of the
inferior epigastric artery and vein throughout
Figure 9.4  A muscle island is isolated with the
pedicle present in the segment. The pedicle can
be visualized traveling on the undersurface of
the muscle.
Figure 9.5  Once the proximal pedicle is isolated,
dissection is continued until sufficient pedicle
length is obtained.
the dissection to avoid injury (Figure 9.5).
It is important to preserve the laterally based
innervation to the lateral segment of the rectus
abdominis muscle.
4. Proximally, the pedicle dissection proceeds in
the same manner as stated previously.
Recipient vessel selection
1. The internal mammary artery and vein are
generally preferred for the recipient vessels. The
thoracodorsal artery and vein are ­typically used
in the setting of a modified radical mastectomy
in which those vessels are skeletonized.
2. Exposure of the internal mammary vessels is
performed at the level of the third or fourth
costal cartilaginous segment and is preferred
based on proximity to the breast pocket,
caliber of the vessels at that level, and ease of
dissection.
3. The medial aspect of the pectoralis major
overlying the selected rib is split parallel to
the muscle fibers using electrocautery.
4. The cartilaginous segment of the rib is freed
from the intercostal muscles using electrocau-
tery, Freer dissecting instruments, and a Doyen
dissector.
5. The dissection extends to the sternal meniscus
and to the junction of the cartilaginous and
osseus portion of the rib.
6. A rib cutter is then used to remove the
­cartilaginous portion of the rib (Figure 9.6).
Figure 9.6  Once the costal portion of the rib
is isolated, a rib cutter is used to remove this
­segment to the sternal junction.

7. The posterior perichondrium is then e­ levated
and removed with tenotomy scissors,
a Jacobsen clamp, and bipolar cautery.
8. Dissection proceeds medially until both the
internal mammary artery and vein are cleared
from the surrounding tissue (Figure 9.7).
Microsurgical anastomosis
1. The usual orientation of the internal m ­ ammary
vessels includes a medial vein and a lateral
artery. Sometimes, a venae commitans is
­present. The medial vein is usually a­ nastomosed
first followed by the artery (Figure 9.8).
Figure 9.7  Careful dissection proceeds, remov-
ing the posterior perichondrium to expose the
internal mammary vein and artery.
Figure 9.8  The internal mammary vein is located
medially with a commitans found in many
patients flanking the internal mammary artery.
The venous anastomosis is typically performed
first, followed by the arterial anastomosis.
Intraoperative details  83
2. My preference is to perform a hand-sewn
venous anastomosis. 8-0 or 9-0 suture is
used in an interrupted fashion. Use of the
­microvascular coupler is also appropriate using
a 2- to 3-mm adapter.
3. Following both anastomoses, flap perfusion is
confirmed with microvascular clamp release.
4. It is important to properly inset the flap such
that the pedicle maintains a gentle sweep
across the pectoralis major muscle without
kinks or twists.
Pedicled TRAM flap
1. The decision to proceed with pedicled transfer
can be made preoperatively or intraopera-
tively. Some surgeons are not comfortable
with microsurgery or feel that a pedicled
TRAM is appropriate in the majority of cases.
Both rationales are reasonable. In some cases
in which a free flap is preferred, there may
be iatrogenic injury to the inferior epigas-
tric vessels that will preclude one’s ability to
perform a free flap and require conversion to
a pedicled TRAM.
2. The pedicled TRAM flap can be harvested
using the entire width of the rectus abdominis
muscle (MS-0) or by sparing the lateral (MS-1)
or medial and lateral segments (MS-2). As with
the abdominal free flaps, preservation of the
laterally based innervation is recommended
when the lateral segment of the muscle is pre-
served. It is our preference to use the ipsilateral
flap for a unilateral or bilateral reconstruction.
The contralateral flap can be used for unilateral
reconstruction as well.
3. The anterior rectus sheath is incised circumfer-
entially around the fascial island and extended
superiorly to the costal margin and inferiorly
as well.
4. The rectus abdominis muscle is divided infe-
riorly using electrocautery, paying attention to
place clips across the inferior epigastric vessels.
5. The flap is then elevated in a caudal-to-cephalad
direction, ensuring that the superior epigastric
artery and vein are protected from injury.
6. At the level of the costal margin, the lateral
muscle is divided to permit greater length
and rotation. The superior epigastric vessels
traverse on the undersurface of the rectus
abdominis muscle.
84  Breast reconstruction with abdominal flaps
7. A tunnel is dissected along the i­ nferomedial
aspect of the breast pocket to allow for the
TRAM flap to be rotated on its pedicle and
to permit proper inset. The width of the
­t unnel is approximately 9 cm, or a hand’s
width.
Recipient site closure
1. If a free flap was performed, care must be taken
to keep the pedicle in line with no kinking or
twisting.
2. To prevent flap malposition, internal tacking
sutures are placed superiorly and medially
with 3-0 Monocryl® (Ethicon, Somerville, NJ)
suture.
3. Flap insetting involves sitting the patient to
approximately 30% and redraping the native
breast skin over the flap. An ellipse is marked
on the flap itself, and the skin outside the
marked ellipse is de-epithelialized.
4. The skin edges are then aligned and sutured
with 3-0 absorbable monofilament (Monocryl)
deep dermal sutures and a 4-0 running subcu-
ticular suture.
Donor site closure
SIEA FLAP
1. The use of two closed-suction drains is
­recommended. Because there are no fascial
incisions, a three-layer adipocutaneous closure
is completed using 2-0 PDS in the Scarpas layer,
3-0 Monocryl in the dermis, and 4-0 Monocryl
subcuticularly. The patient is flexed at the hip
to 30° to f­ acilitate a ­tension-free closure. The
umbilicus is ­exteriorized along the midline and
sutured using either absorbable or nonabsorb-
able sutures.
2. Standard dressings are applied.
DIEP FLAP
The anterior rectus sheath is re-approximated
using a 0 or 2-0 absorbable monofilament suture in
an interrupted figure-of-eight fashion (Figure 9.9).
This repair is oversewn suing 2-0 PDS in a running
continuous fashion. The use of a synthetic or bio-
logic mesh for reinforcement is rarely ­necessary.
The adipocutaneous closure is described in step 1
for the SIEA flap.
Figure 9.9  The donor sites for a free MS-TRAM
(right abdomen) and a DIEP (left abdomen) flap
are shown. Varying degrees of muscle preserva-
tion are shown.
FREE TRAM AND PEDICLED TRAM FLAP
1. When primary fascial closure is p ­ ossible, a two-
layer closure with 2-0 or 0 ­monofilament PDS
suture is recommended. ­Figure-of-eight sutures
are first placed, f­ ollowed by a r­ unning mono-
filament suture for reinforcement.
2. When fascial approximation is possible but
with moderate tension, then primary fascial
closure occurs similar to that described in
step 2 for the SIEA flap with the addition of an
overlay mesh reinforcement. Synthetic mesh
(soft polypropylene) is usually used, but in
some cases, a biologic mesh may be used in
higher-risk patients.
3. If there is a fascial defect that is unable to be
approximated, then an interpositional mesh
is placed under tension with 2-0 PDS suture
fixation. In these situations, a porcine-derived
biologic mesh is usually used, although a syn-
thetic mesh is also effective.
4. In unilateral reconstructions, a contralateral
fascial plication may need to be performed
to improve the abdominal contour and to
center the umbilicus along the midline. If this
is necessary, similar PDS sutures are used in
a two-layer fashion.
5. The skin closure is completed as described
previously.
POSTOPERATIVE DETAILS
1. The abdominal donor site is dressed with a
semi-occlusive dressing on top of ­Steri-Strips™

(3M, St. Paul, MN). The reconstructed breast
incisions are dressed with xeroform or
­Steri-Strips while keeping a majority of the flap
skin visible for postoperative flap monitoring.
2. Aspirin is used postoperatively because of its
antiplatelet effect for prophylaxis against flap
thrombosis. Intravenous antibiotics are used
for 3 days during hospitalization and contin-
ued orally for 1 week.
3. Flap monitoring is crucial during the
­postoperative period. A combination of
­frequent n ­ ursing assessment for color and
­turgor as well as assessment of vascular flow
using the handheld Doppler should be per-
formed every 15 minutes for the first 4 hours,
then every hour for the next 24 hours, and then
every 4 hours for the next 2 days.
4. Assessment of color changes and flap swelling
can suggest early signs of arterial or venous
insufficiency.
5. Tissue oximetry (ViOptix, Fremont, CA)
can be used to aid in flap assessment in the
postoperative period. This tool is sensitive and
has demonstrated success in identifying early
vascular-related flap issues.
6. Aspirin is started on postoperative day 1.
Intravenous heparin or dextran is not used
following microvascular breast reconstruction.
Subcutaneous heparin is considered in patients
with a BMI >30.
7. Patients typically resume a diet on post-
operative day 1 following morning rounds
References 85
and documentation that the flap is viable.
Intravenous fluids are discontinued when the
patient is tolerating oral fluids and diet.
8. Patients typically are instructed to sit in a
chair and to ambulate on postoperative day 1.
Physical and occupational therapy are con-
sulted to assist the patient during her 3-day
hospitalization.
CPT CODING
19364 TRAM with microvascular anastomosis
S2608 DIEP flap
19367 Pedicled TRAM flap
19368 Supercharged TRAM flap
19328 Removal of implant
11971 Removal of tissue expander
19371 Capsulectomy
REFERENCES
1. Man LX, Selber JC, Serletti JM. Abdominal
wall following free TRAM or DIEP flap
reconstruction: a meta-analysis and
critical review. Plast Reconstr Surg. 124:
752–764, 2009.
2. Nahabedian MY, Momen B, Galdino G, and
Manson PN. Breast reconstruction with the
free TRAM or DIEP flap: patient s­ election,
choice of flap, and outcome. Plast Reconstr
Surg. 110: 466–475, 2002.
 10
Nipple reconstruction

DENNIS C. HAMMOND, ELIZABETH A. O’CONNOR, AND JOHANNA R. SHEER

Introduction 88 Intraoperative details 94

Modified skate flap with full-thickness skin graft 88
Preoperative markings 88
Intraoperative details 90
Dressings 91
Purse-string modified skate flap 91
Preoperative markings 91
Intraoperative details 93
Dressings 93
Contralateral nipple sharing 94
Preoperative markings 94
Dressings 94
Skate flap with primary closure 94
Preoperative markings 94
Intraoperative details 94
Dressings 96
Postoperative care 96
Notes 96
CPT coding 97
Suggested Readings 97
Acknowledgment 97

INDICATIONS

1. Nipple reconstruction is indicated for b. Purse-string modified skate flap:

reconstruction after partial or complete nipple
loss due to the following:
a. Mastectomy
b. Necrosis due to complications of breast
surgery
2. Techniques:
a. Modified skate flap with a full-
thickness skin graft: Indicated for
reconstruction of the nipple on
mastectomy skin flaps
Indicated for reconstruction of nipple on
a thicker native breast mound or tissue
flap skin paddle
c. Contralateral nipple sharing: Indicated
for single-nipple reconstruction with
a large native contralateral nipple
d. Skate flap with primary closure:
Indicated for nipple reconstruction with
modest projection and no additional
donor site

Table 10.1  Special equipment

1% lidocaine with epinephrine 1:100,000
Curved tenotomy or face-lift scissors
#11 blade scalpel
Smooth needle drivers (3)
(Continued)

87
88  Nipple reconstruction
Table 10.1 (Continued)  Special equipment
5-0 nylon
5-0 chromic
Vaseline gauze, 5 × 9
Sterile cotton balls
Sterile 4 × 4 gauze
INTRODUCTION
There are several successful techniques for nipple
reconstruction that produce acceptable results.
It is the senior author’s experience that techniques
that use local flaps and primary closure result in
significant loss of projection over time for several
reasons: First, the size of the flaps is often com-
promised to allow for closure. Second, the force of
the scar contracture over time pulls on the recon-
structed nipple, limiting the projection. In con-
trast, use of a full-thickness graft or purse-string
modification allows for generous flaps to be created
that can effectively take into account the inevitable
loss of size over time. Although the purse-string
modification can provide generous amounts of
flap tissue, it requires fairly thick flaps (either a flap
skin paddle or thick mastectomy flaps) to ensure
adequate vascular supply to the fully released areo-
lar and skate flaps. For these reasons, the modified
skate flap with a full-thickness skin graft is our
primary reconstructive technique in the setting
of implant-based reconstruction. The purse-string
modification of the skate flap is our primary recon-
structive technique when a skin paddle is present.
Equipment is listed in Table 10.1.
(a)  
Figure 10.1  Markings and technique for the modified skate flap with full-thickness skin graft. (a) The
anticipated nipple position is determined with the patient in an upright position. (b) The 40- to 44-mm
NAC is marked with a modified skate flap.
MODIFIED SKATE FLAP WITH
FULL-THICKNESS SKIN GRAFT
Preoperative markings
The patient is always marked in the upright
position.
1. The position of the reconstructed nipple-
areolar complex (NAC) must be determined
first. In the case of unilateral reconstruction,
symmetry with the contralateral NAC will
determine the location. In bilateral reconstruc-
tion, the new NAC positions will be placed
symmetrically at the point of maximal projec-
tion of the breast. We utilize prosthetic nipples
or electrocardiograph (ECG) patches to guide
positioning of the new NAC(s) (Figure 10.1a).
2. A 40- to 44-mm areolar diameter is traced at
the identified NAC site. The center of the areola
is marked with a 5- to 10-mm diameter circle,
which represents the position of the nipple.
3. A modified skate flap is diagramed, creating
wings approximately 1 cm wide on both sides
and a mosque-shaped cap. The base, which is the
vascular pedicle, should remain approximately
(b)
(Continued)
 Modified skate flap with full-thickness skin graft  89

(c)   (d)

(e)   (f )

(g)   (h)

Figure 10.1 (Continued)  Markings and technique for the modified skate flap with full-thickness skin
graft. (c) The areolar portion of the NAC has been de-epithelialized. (d) The skate flap has been
elevated with a thin layer of fat on the undersurface. (e) The skate flap wings have been approximated
and the cap draped over and sutured into place. (f) The full-thickness graft has been sutured over
the nipple reconstruction with additional bolster sutures placed. A circle has been marked in the
center of the graft corresponding with the size and position of the underlying nipple. (g) The nipple
reconstruction has been delivered through the hole in the center of the graft and sutured at the base.
The graft has been perforated in a piecrusting fashion. (h) The graft and nipple reconstruction are
dressed with Vaseline gauze. (Continued)
90  Nipple reconstruction

(i)   (j)

(k)

Figure 10.1 (Continued)  Markings and technique for the modified skate flap with full-thickness skin
graft. (i) Saline-moistened cotton balls are placed over the graft. (j) The bolster is wrapped over the
graft and secured with bolster sutures. (k) Healed postoperative appearance of modified skate flap
with full-thickness skin graft.

1 cm wide and be oriented to maximize v­ ascular
supply. In other words, the pattern may be
rotated to position the base toward a scarless
area of the mastectomy skin, which optimizes
the blood flow. The pattern should be slightly off
center, skewing the entire design toward the cap,
as it will be pulled toward the base of the flap
when elevated (Figure 10.1b).
4. The 40- to 44-mm areolar pattern is traced into
a groin crease for harvest of a full-thickness
skin graft. To allow for removal of the dog-ear,
an elliptical pattern is drawn around the iden-
tified graft, following the relaxed skin tension
lines. Alternatively, any pre-existing scar line
on the abdomen or back may be used as the
donor site.
Intraoperative details
1. The breast and groin patterns are infiltrated
with 1% lidocaine with epinephrine 1:100,000.
2. The entire NAC pattern is incised through
­epidermis only. The portion of the areola sur-
rounding the skate flap is de-epithelialized super-
ficially (Figure 10.1c). The skate flap is raised,
retaining a thin, even layer of fat on the under-
surface of the flap (Figure 10.1d). Care is taken to
leave the base and the associated vascular supply
intact. The pattern is elevated until the wings eas-
ily wrap around the pattern without tethering.
3. The skate-flap wings are approximated end to
end, and the cap is draped onto the approxi-
mated wings. This is sutured with interrupted
5-0 chromic sutures (Figure 10.1e).
4. The full-thickness skin graft is harvested from
the groin, taking the circular areolar pattern first
and then removing the surrounding ellipse.
5. The graft is thinned meticulously with curved
scissors until it is a thin full-thickness graft
that is nearly transparent.
6. The graft is sutured over the nipple reconstruc-
tion with interrupted 5-0 nylon sutures equally

divided at eight cardinal points, and the tails
are left long to function as a bolster tie-over.
A running 5-0 nylon suture is used to secure
the entire diameter of the graft.
7. A circle of the same size as the reconstructed
nipple is marked on the center of the graft and
excised with curved scissors (Figure 10.1f).
The reconstructed nipple is exposed through this
perforation in the graft. The base of the nipple is
sutured to the graft with interrupted 5-0 ­chromic
sutures. An 11 blade is used to piecrust the graft
and allow for serous drainage, which can impede
graft take (Figure 10.1g).
Dressings
1. A Vaseline® (Unilever, Trumbull, CT) gauze
and cotton ball bolster is then placed over the
graft. A 1-cm hole is cut in the center of the
Vaseline gauze, which is then placed over the
NAC, with the nipple exposed through the hole
(Figure 10.1h). Saline-moistened cotton balls
are placed on the Vaseline gauze (Figure 10.1i).
The bolster is then wrapped and secured by the
tie-over suture tails using smooth needle driv-
ers (Figure 10.1j).
2. The bolster is covered with light 4 × 4 gauze
and secured with paper tape. No bra or pres-
sure should be placed on the reconstruction.
3. The groin donor site is closed with interrupted
4-0 monofilament deep dermal sutures and a
3-0 barbed monofilament subcuticular suture.
4. Tattooing is delayed for approximately
6 months to allow for full healing of the graft
(a)  
Figure 10.2  Markings and technique for the purse-string modified skate flap. (a) The purse-string
modified skate flap pattern has been marked on a latissimus skin paddle. Note the oval shape of
the NAC, which accounts for the height of the skate flap wings. (b) The skate flap pattern has been
elevated with a thin layer of fat until the wings can easily wrap without tethering.
Purse-string modified skate flap  91
and complete settling of the nipple. Once
­completed, a realistic and natural-appearing
NAC is the result (Figure 10.1k).
PURSE-STRING MODIFIED
SKATE FLAP
Preoperative markings
The patient is always marked in the upright
position.
1. The nipple position is determined as previously
detailed.
2. A 5- to 10-mm circular pattern is drawn to
mark the new nipple site.
3. The pattern is then drawn on the skin paddle,
which may either be done at the first or second
stage. The horizontal width of the areola is
marked at 40–44 mm, and skate-flap wings are
drawn at approximately 1 cm in width.
4. The cap is drawn as a mosque pattern approx-
imately 1 cm in height. When the skate-flap
wings are elevated, the vertical height of
the areola will be the marked height minus
the width of those flaps. For this reason, the
­a reolar pattern is oval in shape, with the
height longer than the width. For the areo-
lar pattern surrounding the cap, the vertical
height is marked 20–22 mm from the center
of the cap. The vertical height of the areo-
lar pattern by the base of the flap is marked
20–22 mm from the center of the nipple
(Figure 10.2a).
(b)
(Continued)
92  Nipple reconstruction

(c)   (d)

(e)   (f )

(g)

Figure 10.2 (Continued)  Markings and technique for the purse-string modified skate flap. (c) The
skate flap pattern has been elevated with a thin layer of fat until the wings can easily wrap without
tethering. (d) A thin layer of fat is elevated with the flaps. (e), (f) The medial and lateral edges of
the areolar pattern are also elevated to allow for tension-free closure. (g) The skate flap wings have
been approximated and cap draped over and sutured. The surrounding areolar pattern is brought
together and sutured.  (Continued)

(h)  
(j)
Figure 10.2 (Continued)  Markings and technique for the purse-string modified skate flap. (h), (i) The
interlocking purse-string suture is placed and secured. (j) Healed postoperative appearance of the
modified purse-string skate flap.
Intraoperative details
1. The recipient and donor sites are infiltrated
with 1% lidocaine with epinephrine 1:100,000.
2. The entire pattern is incised through full-
thickness skin, and the skate-flap wings and
cap are elevated until the wings easily wrap
around the pattern to meet without tethering,
leaving the base and the associated blood sup-
ply intact (Figure 10.2b, c). A thin, even layer of
fat is retained on the undersurface of the skate
flap (Figure 10.2d).
3. The areolar flaps are fully released at the inner
and outer aspects for 2–3 mm to allow these
to slide together easily without tethering
(Figure 10.2e, f).
4. The skate wings are approximated end to
end, and the cap is draped onto the re-­
approximated wings. This is sutured with
interrupted 5-0 chromic sutures. The areolar
patterns are advanced toward each other and
secured with interrupted 4-0 monofilament
Purse-string modified skate flap  93
(i)
deep dermal sutures. A running 5-0 chromic
suture is used to close the areolar incision and
inset the reconstructed nipple (Figure 10.2g).
5. The peripheral areolar pattern is undermined
laterally 1–2 cm and closed with an interlock-
ing purse-string polytetraethylfluorane suture
on a Keith needle (Figure 10.2h, i). This is
followed by a running subcuticular suture with
3-0 barbed monofilament.
Dressings
1. The incision lines are covered with Vaseline
gauze, and 4 × 4 gauze is placed around the
nipple site to protect it from compression.
A single 4 × 4 is used to cover the nipple.
2. The dressing is secured with paper tape.
3. Tattooing can be performed after 6 weeks
as the flaps are essentially comprised of
­f ull-thickness normal skin, resulting in a
realistic-appearing NAC that is resistant to
significant atrophy (Figure 10.2j).
94  Nipple reconstruction
CONTRALATERAL NIPPLE SHARING
Preoperative markings
The patient is always marked in the upright
position.
1. The reconstructed nipple position is deter-
mined as previously detailed.
2. A 5- to 10-mm circular pattern is drawn to
mark the nipple site (Figure 10.3a).
3. The contralateral nipple is marked to
­identify two equal halves. A mid-sagittal
­section is traced and then carried around the
base of one of the lower halves.
Intraoperative details
1. The recipient and donor sites are infiltrated
with 1% lidocaine with epinephrine 1:100,000.
2. The recipient bed is prepared by de-­
epithelializing the circular pattern
(Figure 10.3b).
3. The donor nipple is transected sagittally and
along the base on the lower half of the circum-
ference to completely release the inferior half of
the nipple (Figure 10.3c).
4. The nipple graft is transferred to the recipient
bed and secured with interrupted 5-0 chromic
sutures (Figure 10.3d).
5. The remaining half of the nipple is used to
close the donor site. The nipple is folded down
onto the open surface and secured with inter-
rupted 5-0 chromic sutures (Figure 10.3e).
(a)  
Figure 10.3  Markings and technique for contralateral nipple sharing. (a) The anticipated nipple
­position is marked by a 5- to 10-mm circular pattern with the patient in the upright position.
(b) The recipient bed has been de-epithelialized.
Dressings
1. The incision lines are covered with
Vaseline gauze, and 4 × 4 gauze is placed
around the nipple site to protect it from
­compression. A single 4 × 4 is used to cover the
nipple.
2. The dressing is secured with paper tape.
SKATE FLAP WITH PRIMARY
CLOSURE
Preoperative markings
The patient is always marked in the upright
position.
1. The reconstructed nipple position is deter-
mined as previously detailed.
2. The NAC pattern is drawn at a 40- to 44-mm
diameter.
3. A skate-flap pattern is drawn with wings that
are approximately 1 cm wide with a 1-cm base
and a mosque-shaped cap. The wings extend
to the edge of the NAC pattern. The ends of
the skate-flap pattern are tapered to allow a
contoured closure (Figure 10.4a).
Intraoperative details
1. The entire pattern is infiltrated with 1% lido-
caine with epinephrine 1:100,000.
2. The skate-flap wings and cap are elevated, tak-
ing care to leave the base and associated blood
(b)
(Continued)
 Skate flap with primary closure  95

(c)   (d)

(e)

Figure 10.3 (Continued)  Markings and technique for contralateral nipple sharing. (c) The donor nipple
has been harvested by removing one-half of the nipple in a sagittal section. (d) The graft is sutured to
the de-epithelialized bed. (e) The donor site is closed by draping the remaining nipple down over the
defect and suturing closed.

(a)   (b)

Figure 10.4  Markings and technique for skate flap with primary closure. (a) A 40- to 44-mm diameter
NAC marking with a skate flap is demonstrated. The ends are then tapered to allow for removal of
standing cones for closure. (b) The skate flap has been elevated and the wings and cap sutured into
place. The donor site will be closed primarily (see arrows). (Continued)
96  Nipple reconstruction
(c)  
Figure 10.4 (Continued)  Markings and technique for skate flap with primary closure. (c) The skate flap
has been elevated and the wings and cap sutured into place. (d) The completed nipple reconstruction
with donor site closed.
supply intact. A thin, even layer of fat is kept
with the flap (Figure 10.4b).
3. The pattern is elevated until the wings can eas-
ily wrap around without tethering.
4. The wings are approximated end to end and the
cap draped over the top of the re-­approximated
wings. This is closed with interrupted 5-0 chro-
mic sutures (Figure 10.4c).
5. The donor area at the base is re-­approximated
with 4-0 deep dermal monofilament sutures
and interrupted 5-0 chromic sutures
(Figure 10.4d).
Dressings
1. The incision lines are covered with Vaseline
gauze, and 4 × 4 gauze is placed around
the nipple site to protect it from compres-
sion. A single 4 × 4 is used to cover the
nipple.
2. The dressing is secured with paper tape.
POSTOPERATIVE CARE
Dressings are removed in the clinic at the 1-week
postoperative visit. All nylon sutures are removed
at this time. For the modified skate flap with skin
graft technique, the peripheral NAC (which is
(d)
where the skin graft meets the native skin) is then
reinforced with paper tape. The nipple is protected
by a double layer of nursing pads; the inner pad has
a hole cut for the nipple. A loose-fitting bra may
be worn at this time. For 4 weeks postoperatively,
this dressing is replaced by the patient daily after
showering.
NOTES
The senior author has modified his technique and
pattern over the past 20 years. Several key modifi-
cations have helped create consistent and sustain-
ing results.
1. The skate wings must not be shorted in an
effort to spare breast skin. Skin graft closure
(see the modified skate flap with skin graft
technique) is an effective way to allow adequate
flap size and not distort the breast with primary
closure. In addition, bringing the skate wings
together end to end maximizes the nipple
size, while any patterns that overlap the wings
around each other will tend to limit the overall
volume of the reconstructed nipple.
2. The cap is often drawn as an oval pattern.
The senior author has found that modification
into a mosque-shaped pattern creates a more

aesthetically pleasing dome shape to the apex
of the reconstructed nipple.
3. Nylon sutures should be removed at 1 week
to avoid long-term scarring around the
NAC. Paper tape may be applied to the graft
edges at that point to ensure stability of the
skin graft.
4. The purse-string modification of a skate graft
may be done on a flap skin paddle at the first
stage or delayed until the second stage. If it is
done at the second stage, the paddle should
be oval shaped to allow for the fact that a
segment of tissue will be removed from the
middle of the pattern to reconstruct the nipple
(see ­previous description).
CPT CODING
19350 Nipple reconstruction
Acknowledgment 97
SUGGESTED READINGS
1. Gruber RP. Nipple-areolar reconstruction.
Clin Plast Surg. 6:71, 1979.
2. Hammond DC, Khuthaila DK, Kim J.
Interlocking Gore-Tex suture for control of
areolar diameter and shape. Plast Reconstr
Surg. 119:804, 2007.
3. Hammond DC, Khuthaila D, Kim J. The
skate flap purse-string technique for
nipple-areolar complex reconstruction. Plast
Reconstr Surg. 120:2, 2007.
4. Jones G, Bostwick J III. Nipple-areolar
reconstruction. Oper Techniques Reconstr
Plast Surg. 1:35, 1994.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 Part     3
Maxillofacial

11 Unilateral and bilateral cleft lip repair 101

Rizal Lim, Catherine Gordon, and Seth R. Thaller
12 Cleft palate repair: The Furlow double-opposing Z-plasty, the Von Langenbeck
palatoplasty, and the V-Y pushback palatoplasty 111
Jason W. Edens, Samuel Golpanian, Kriya Gishen, and Seth R. Thaller
13 Orbital floor fracture 123
Urmen Desai, William Blass, and Henry K. Kawamoto
14 Mandible fracture management 133
Larry H. Hollier Jr., Amy S. Xue, and Edward Buchanan
15 Zygomatic and zygomaticomaxillary complex (ZMC) fractures 139
David E. Morris and Mimis N. Cohen
 11
Unilateral and bilateral cleft lip repair

RIZAL LIM, CATHERINE GORDON, AND SETH R. THALLER

Introduction 102 Bilateral cleft lip repair 106

Anatomic landmarks important to cleft
lip repair 102
Associated anatomic malformations 102
Patient positioning 104
Unilateral cleft lip repair 104
Intraoperative details 105
CPT coding 106
Preoperative markings 106
Intraoperative details 107
Postoperative care 109
Notes 109
CPT coding 109
References 109
Acknowledgment 109

INDICATIONS

1. Presence of cleft lip b. Difficulties with speech

2. Desire for improved nasolabial appearance c. Poor self-esteem due to appearance
and function d. Malocclusion of the teeth
3. Residual secondary cleft lip deformities:
a. Inadequate weight gain due to poor feeding

Table 11.1  Special equipment

Preoperative antibiotics: cefazolin 25 mg/kg IV or clindamycin 20 mg/kg IV (optional)
Double-prong hook
Single-prong hook
Supersharp® Micro Feather disposable ophthalmic scalpel with plastic handle
#11 blade
#15c blade
Castroviejo surgical caliper
25-gauge hypodermic
Adson-Brown forceps
Methylene blue (for preoperative markings)
30-gauge needle
Senn-Muller surgical retractor
(Continued)

101
102  Unilateral and bilateral cleft lip repair

Table 11.1 (Continued)  Special equipment

4-0 Monocryl® (Ethicon, Somerville, NJ) or equivalent
5-0 Prolene® (Ethicon) or equivalent
4-0 chromic gut
4-0 Vicryl Rapide™ (Ethicon) or equivalent
Lidocaine (1%) with epinephrine (1:200,000)

INTRODUCTION
Cleft lip malformations are due to embryologic
alterations in the fusion of the frontonasal and
­
maxillary prominences of the first branchial arch.
Included anatomic malformations include discon-
tinuity and anomalous insertion of orbicularis oris
and altered naso-pharyngeal development.1 This
results in poor feeding, subsequent inadequate
weight gain, as well as speech difficulties. Cleft
lip consists of a spectrum, including microform
clefts, unilateral incomplete, unilateral complete,
bilateral incomplete, and bilateral complete types.
Incomplete clefts are characterized by the orbicu-
laris discontinuity without involvement of the nasal
vestibule. Complete clefts involve the nasal vestibule
and alveolar ridge and may extend onto the palate.
When correcting this deformity, plastic surgeons
should keep in mind not only the three-­dimensional
flap rotations but also the “fourth dimension” of Figure 11.1  Important equipment, i­ncluding
the effect of time and growth on the repair.2 Our Supersharp ophthalmic blade, skin hooks,
­preferred operative techniques are based on a low toothed f­ orceps, Senn retractors.
complication rate and decreased visibility of scar-
ring with selected procedures. Table  11.1 and philtral dimple. Borders of the philtrum are the
Figure 11.1 indicate special equipment needed. philtral columns.
5. White roll: The prominent border between
ANATOMIC LANDMARKS cornified squamous epithelium of the lip and
IMPORTANT TO CLEFT LIP REPAIR the vermillion border.
(FIGURE 11.2) 6. Median tubercle of the lip: The median vermil-
lion prominence of the upper lip.
1. Nasal tip: The point of the nose created by the 7. Cupid’s bow: Describes the curved shape of
midline abutment of the greater alar cartilage the epidermal-vermillion border junction of
apices. the upper lip at the philtrum. Philtral columns
2. Nasal ala: Formed by greater alar cartilages adjoin the two “peaks” of the Cupid’s bow.
and fibro-fatty connective tissue; it defines
the nasal vestibule. ASSOCIATED ANATOMIC
3. Columella: The midline central “pillar” of the MALFORMATIONS (FIGURES 11.3
nose formed by bilateral medial crura of the AND 11.4)
nasal cartilages, nasal septal cartilage, and
anterior maxillary spine. 1. Flattened and widened ipsilateral nasal alar
4. Philtrum: The midline portion of the upper cartilage; is on both sides in bilateral clefts.
lip defined by the central depression; it is 2. Rotated nasal tip in unilateral clefts; flattened
also termed the infranasal depression or nasal tip in bilateral cleft lip.
 Associated anatomic malformations  103

Figure 11.2  Anatomic landmarks: 1, nasal tip; 2, nasal ala; 3, columella; 4, philtrum; 5, white roll;
6, median tubercle; 7, Cupid’s bow.

4
2,3

Figure 11.4  Associated anatomic ­malformations:

1, bilateral flattened, wide nasal ala; 2, rotated
nasal tip; 3, shortened rotated columella;
4, prolabium.

Figure 11.3  Associated anatomic malformations:

1, cleft side flattened, wide nasal ala; 2, broad
nasal tip; 3, shortened columella.
104  Unilateral and bilateral cleft lip repair

3. Shortened rotated columella, toward the cleft
side.
4. Downturned ipsilateral nostril.
5. Prolabium: The undifferentiated nasofrontal
tissue found in bilateral complete clefts used
to reconstruct the philtrum.
Patient positioning
After the induction of general endotracheal anesthe-
sia, the tube is secured in the midline. Temperature,
oximetry, electrocardiogram (ECG), blood pressure,
and respiration monitoring should be in place,  as
well as placement of active warming devices.
The  patient is positioned on a Philippine board
with the head suspended off the end in an extended
position on a gel donut or head roll. Eyes are lubri-
cated and taped closed. We prefer to use Tegaderm™
(3M, St. Paul, MN) to keep any blood and Betadine®
(Purdue Products, Stamford, CT) out of the eyes.
After this, the face is prepped with Betadine paint.
UNILATERAL CLEFT LIP REPAIR
The preferred method is an adaptation of
­advancement-rotation unilateral cleft repair because
of its re-creation of Cupid’s bow and avoidance of
philtral flattening.3 In addition, the incision lines are
hidden within the nasolabial sulcus and simulated
philtral ridge. Malformation can be conceptualized
as medial and lateral elements. Medial elements
are rearranged to re-create the philtrum and phil-
tral ridge. Lateral elements are separated into the
nasal elements and lateral flap. Nasal elements are
brought medially to reshape the nasal flattening.
Preoperative markings are shown in Figure 11.5.
1. Identify the midline of the planned philtrum
at the epidermal-vermillion border. Mark the
non–cleft-side peak of Cupid’s bow at the base of
the philtral column (point A), then an equidis-
tant point from the midline toward the cleft side
along the epidermal vermillion border (point B).
A curvilinear line between points A and B
creates the handle of Cupid’s bow. The total
distance between points A and B should be
between 3 and 4 mm; this can be tailored to
the patient’s facial and ethnic proportions.
2. Mark the proposed peak of the Cupid’s bow on
the lateral complex of the cleft side (point C).
Point C will meet point B in closure. This point
can be determined by locating the point on
the lip where the vermillion is thickest and the
white roll begins to fade. The distance from
point A to the non–cleft-side commissure
should be equal to the distance from point C
to the cleft-side commissure.

Figure 11.5  Preoperative markings for unilateral cleft repair with demonstration of final repair; point A
is the base of the non–cleft-side philtral column; point B is the base of the proposed cleft-side philtral
column. Point D is the two-thirds point of the nasal columellar junction; incision is between points B
and D. Division of point D separates the philtrum from the medial cutaneous flap and allows rotation
and lengthening of the philtrum. Point C insets to point B, while point E insets to point D.
 Unilateral cleft lip repair  105

3. Mark along the junction between the

­philtrum and columella approximately
two-thirds its width on the non–cleft side
(point D). Then, mark a convex curvilinear
line between this point and point B. This
line separates the proposed columella from
the medial cutaneous flap (depicted by gray
shading in Figure 11.5) from the proposed
philtrum; this incision line allows rotation
of the philtrum inferiorly and lengthening of
the cleft side. Further rotation of the proposed
philtrum can be achieved with a back cut
extending from point D toward the peak of
the Cupid’s bow on the non–cleft side; this
back cut should run parallel to but not cross
the non–cleft philtral column. Mark along
the epidermal-vermillion border lateral to the
medial cutaneous flap; this incision ­creates
the lateral vermillion flap.
4. Mark along the lateral border of the ala and Figure 11.6  Dissection of the lateral cutaneous
extend to the mucocutaneous junction, then and vermillion flaps from the orbicularis oris.
extend caudally along the white roll to point C.
This creates the lateral cutaneous flap and
lateral vermillion flap; the apex of the lateral
flap will be point E; this will meet point D on DISSECTION OF LATERAL ELEMENTS
closure. 1. Along the lateral elements, carry the
5. The length of point C to E should be equal to ­epidermal-vermillion incision along the white
the length from point B to D. roll incision vertically onto the nasal mucosa
of the vestibule. Completion of the lateral flap
Intraoperative details should divide the nasolabial line, s­ eparating
the lateral flap from the nasal alae. Using
After creation of the marks, inject lidocaine with double-prong hooks for retraction, elevate
epinephrine along the marked lines. the lateral flap and lateral vermillion flap off
the orbicularis.
DISSECTION OF MEDIAL ELEMENTS 2 . Incise the anomalous lateral insertion
1. After allowing adequate time for e­ pinephrine of o ­ rbicularis oris from the base of the
to take effect (7–10 minutes), incise the lines cleft-side ala.
using the Supersharp ophthalmic blade. Incise 3. The white roll incision along the lateral
the vermillion epidermal junction of the ­elements is carried anterior to the inferior
medial cutaneous flap. ­turbinate into the nasal vestibule. This will
2. Complete the incisions with a #11 blade. Use allow access to the nasal tip and the lateral
double-prong skin hooks for retraction and lower cartilage for reshaping of the ipsilat-
elevation of the flaps. Start with the philtral eral nose. In addition, this will allow more
rotational flap by incising between points B length of the lateral cutaneous flap for wide
and D. Using skin hooks for retraction, dissect defects.
the philtral flap and medial cutaneous flap 4 . Through this incision, dissect the skin
away from the orbicularis oris (Figure 11.6). away from the nasal alar cartilage on both
3. Complete the dissection of skin and vermillion the ipsilateral and the contralateral side
flaps away from the orbicularis oris. (Figure 11.7). Raise the mucosal flaps within
4. Incise the anomalous medial insertion of orbi- the nasal vestibule along both lateral and
cularis oris on the columella. medial elements.
106  Unilateral and bilateral cleft lip repair
Figure 11.7  Blunt dissection of the skin from
the alar cartilages allows reshaping of the
nasal tip.
CLOSURE
1. Close the orbicularis oris with 4-0 Monocryl
or equivalent suture in a horizontal mattress
fashion.
2. Approximate the base of the nasal ala to the base
of the columella. Close the nasal ala by transpos-
ing the alar base medially toward the medial flap
with 4-0 Monocryl. Close the mucosa within the
nasal vestibule with 4-0 chromic gut suture.
3. Approximate the lateral flap to the philtrum.
Trim extra skin as needed to achieve symmetry
with the unaffected side. Close the flaps with
4-0 Vicryl Rapide.
4. Nasal vestibular epidermis and alar cartilages
are reshaped with trans-cartilaginous 5-0
Prolene bolsters (Figure 11.8).
5. Close the vermillion with 4-0 Vicryl Rapide.
Excess vermillion may be trimmed as needed for
symmetry and approximation (Figure 11.5).
6. Apply Steri-Strips™ (3M, St. Paul, MN) across
the lip closure from cheek to cheek.
CPT CODING
13151 Repair, complex, eyelids, nose, ears, and/or
lips; 1.1 cm to 2.5 cm
40700-52 Plastic repair of cleft lip/nasal defor-
mity; primary, partial or complete, unilateral;
reduced services
Figure 11.8  Final closure of a unilateral cleft
repair; transcartilagenous bolsters are demon-
strated for reshaping of the nasal tip.
407001-52 Primary bilateral, one-stage procedure;
reduced services
42281 Insertion palatal prosthesis
BILATERAL CLEFT LIP REPAIR
The preferred method for bilateral repair is an
adaptation of the technique described by Mullikan
et al.2 This is due to its reconstruction of the phil-
trum, re-creation of the Cupid’s bow, and primary
alar reconstruction. We repair all the defects at
once, including the alveolar defects, as opposed to
the traditional multistage repair.
Preoperative markings (Figure 11.9)
Markings should be made with an intraoperative
marker, then outlined in methylene blue tattoo.
1. Mark the midline of the prolabium and the lip.
2. Mark 2 mm on either side of the midline at
the  lip for the proposed Cupid’s bow peaks
(points A).
3. Mark 1–1.25 mm on either side of the midline
at the columellar-labial junction (points B).
4. Connect these markings to outline the pro-
posed philtral flap. Adjacent skin on both sides

Figure 11.9  Preoperative markings for bilateral
cleft lip repair; the philtral flap is outlined by points
A to B.
of the philtral flap will be de-epithelialized to
help simulate the prominence of the philtral
columns. Alternatively, the prolabial skin can
be divided into three, creating the so-called
forked flap, by which the central portion will
be used to construct a philtrum and the two
lateral portions can be used to restore continu-
ity to the floor of the nasal vestibule or can be
de-epithelialized. This technique may be used
in situations where the defect is wide.
5. Mark the proposed Cupid’s bow peaks on
the lateral labial elements at the vermillion-­
cutaneous junction (points C).
6. Mark the alar bases in a curvilinear fashion
and extend caudally to the lateral markings of
the Cupid’s bow peaks on the lateral elements.
The vermillion flap of the lateral element re-
creates the median tubercle. Detachment of the
ala from the lateral element allows reshaping of
the splayed alar cartilages.
Intraoperative details
Inject lidocaine with epinephrine into the nasal
and labial areas.
LATERAL LABIAL DISSECTION
1. Use a Supersharp blade to incise the markings
from the lateral cutaneous flaps to the nasal
border and around the alar base.
2. Follow the incision with a #11 blade
(Figure 11.10); de-epithelialize the zones ­lateral
to the philtral flap. (Note: Use electrocautery to
Bilateral cleft lip repair  107
Figure 11.10  Elevation of cutaneous and mucosal
flaps; philtral flap is retracted rostrally. The lateral
cutaneous flaps are dissected away from orbicu-
laris oris.
control labial artery bleeding, applying digital
pressure to the lip to prevent major blood loss.)
3. Use a #15c blade to dissect out the orbicularis
oris muscle from the lip.
4. Use a double hook to retract the lip while dissect-
ing the lateral cutaneous flap off the muscle and
maxilla extending over the malar process in the
supraperiosteal plane. Maintain continuous pres-
sure to monitor the thickness of the muscle flap.
5. Repeat on the contralateral side.
NASAL DISSECTION
1. Using bilateral rim incisions, dissect under the
ala bilaterally around to the top of the lower
lateral cartilage with scissors, freeing the skin
(Figure 11.11).
2. Check for mobility.
PROLABIAL DISSECTION
1. Follow philtral flap markings with a
Supersharp blade, then follow with a #15 blade
on both sides.
2. Fan out the incisions along the philtral flap.
3. Use scissors to undermine the flap,
then ­elevate; take care not to devascularize
the flap.
4. If using fork flaps, they may be rotated laterally
to form the medial lining of the nasal floor.
108  Unilateral and bilateral cleft lip repair

Figure 11.11  Nasal alar dissection through

­bilateral alar rim incisions; lateral zones of skin
of the prolabium are de-epithelialized to aid
in re-­creating the philtral columns and philtral Figure 11.12  Closure of orbicularis oris; this
dimple. ­muscular closure involves approximating
­muscle from each lateral element in the midline.
This ­closure should lie deep to the philtral flap.
NASAL FLOOR FORMATION
1. Elevate the mucosal flaps laterally and medially
within the nasal vestibule, bringing together
the mucosa lining the lower lateral cartilage
and the mucosa lining the medial side of
the columella. If fork flaps are used, they may
be incorporated into the nasal floor closure.
2. Close with a 4-0 chromic gut suture.
3. Alveolar defects may be closed by elevating and
closing the gingivomucoperiosteal flaps using
4-0 chromic sutures.
Figure 11.13  Intraoperative photo of bilateral
CLOSURE
cleft repair following muscular closure with
1. Use Monocryl 4-0 to close the septum to the ­philtral and lateral flaps in place.
outer nostril on both sides.
2. Place another stitch connecting the bottom of
the ala to the septum if necessary. bow peaks and stitch along the edge of the
3. Attach the orbicularis oris muscle of the ­prolabium to the columellar-labial junc-
­lateral elements end to end in the mid- tion and along the alar bases on both
line using at least two horizontal mat- sides using horizontal mattress stitches
tress stitches; tie both down at the same and 4-0 Vicryl Rapide in the skin; be
time to prevent t­ earing of the muscle. ­careful to align the vermillion-­cutaneous
When closed, the ­orbicularis oris should ­junction (Figure 11.14).
be deep to the p ­ hiltral flap and anterior 5. Sharply remove excess vermillion tissue in the
to the alveolar segment of the prolabium midline, then close using horizontal mattress
(Figures 11.12 and 11.13). stitches (Figure 11.15).
4. Bring the lateral labial edges to meet the 6. Apply Steri-Strips across the lip closure from
­philtral column at the proposed Cupid’s cheek to cheek.

Figure 11.14  Closure of bilateral cleft lip repair.
Postoperative care
Give red rubber catheter feedings for 7–14 days;
the patient may breast-feed; bottle feeding is
allowed in 2 weeks.
Discharge the next day if oral intake is adequate.
Give a Tylenol® (McNeil, Philadelphia, PA)
­suppository prior to extubation.
Notes
Avoid distractions for these surgeries, and do them
as early cases.
CPT CODING
13151 Repair, complex, eyelids, nose, ears, and/or
lips; 1.1 cm to 2.5 cm
40700-52 Plastic repair of cleft lip/nasal defor-
mity; primary, partial or complete, unilateral;
reduced services
Acknowledgment 109
Figure 11.15  Intraoperative photo of bilateral
cleft repair at completion of closure.
407001-52 Primary bilateral, one-stage procedure;
reduced services
42281 Insertion palatal prosthesis
REFERENCES
1. Losee JE, Kirschner RE. Comprehensive
Cleft Care. New York, NY: McGraw-Hill
Medical; 2009.
2. Mulliken JB, Wu JK, Padwa BL. Repair
of bilateral cleft lip: review, revisions,
and reflections. J Craniofac Surg.
2003;14(5):609–620.
3. Salyer KE, Rozen SM, Genecov ER,
Genecov DG. Unilateral cleft lip—
approach and ­technique. Semin
Plast Surg. 2005;19(4):313–328.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 12
Cleft palate repair: The Furlow double-
opposing Z-plasty, the Von Langenbeck
palatoplasty, and the V-Y pushback
palatoplasty

JASON W. EDENS, SAMUEL GOLPANIAN, KRIYA GISHEN,

AND SETH R. THALLER

Introduction 112 Postoperative care 121

Operative technique 112 Notes 121
The Furlow double-opposing Z-plasty 114 CPT coding 121
The Von Langenbeck procedure 116 References 122
V-Y palatal pushback procedure 118 Acknowledgment 122

INDICATIONS

1. All patients with cleft palate should be 3. Prevention of feeding abnormalities, nasal
considered for repair.1 regurgitation, and nasopharyngeal mucosal
2. Avoidance of speech disturbances, irritation.
communication impairments, and hearing loss.1

Table 12.1  Special equipment

Measuring ruler
Dingman retractor
Small, medium, and large tongue blades
Adson-Brown, Gerald, and Bayonet forceps
Double-prong skin hooks
Webster, Crile-Wood, and Castroviejo needle holders
Curved iris, Metzenbaum, and Stevens tenotomy scissors
(Continued)

111
112  Cleft palate repair
Table 12.1 (Continued)  Special equipment
Cottle periosteal elevator
Kleinert Kutz periosteal elevator
Obwegeser periosteal elevator
Cleft palate raspatory and sharp hook
Angled Beaver lamellar blades (60° bevel up)
Mallet
2-mm osteotome
2-mm chisel
Surgicel Nu-Knit
INTRODUCTION
Worldwide, orofacial clefting, whether s­ yndromic
or non-syndromic, occurs in approximately 1 of
every 500–700 live births. Clefting of the ­palate
can occur with or without cleft lip. Isolated
cleft palate, not associated with any other con-
genital malformations, occurs in 0.5 of 1000
births regardless of race. It is more frequently
encountered in females (57% of isolated cleft
palate patients). Conversely, clefting of the lip,
whether isolated or associated with cleft palate,
occurs with twice the frequency in males than in
females.2 Normal anatomy and cleft anatomy are
shown in Figure 12.1.
Cleft palates are classified as primary if they are
located anterior to the incisive foramen; when pos-
terior, they are considered secondary. Primary and
secondary cleft palates can be further subdivided
into unilateral or bilateral (see Table 12.2 for Veau
classification3,4). Left unilateral cleft palate occurs
twice as frequently as right-sided cleft palate.
Unilateral cleft palate is nine times more common
than bilateral cleft palate.2
Regardless of cleft classification, surgery is nec-
essary to create a free, intact palate with adequate
mobility and functional musculature. The goal is to
separate the oral and nasal cavities. Many studies
advocate early surgery, usually from 6 to 18 months
of age, although some surgeons have performed
palatoplasties later in life, around the age of 2 to
3 years or even older.5 Proponents of earlier surgery
believe that there are improved speech outcomes
and decreased incidence of hearing loss. However,
others believe that it may lead to maxillary growth
retardation6 with associated dentofacial deformi-
ties. This may require later corrective orthognathic
procedures.
Three widely utilized operative techniques are
outlined in this chapter: the Furlow double-­opposing
Z-plasty, the Von Langenbeck palatoplasty, and the
V-Y palatal pushback. The Furlow procedure aims
to lengthen the soft palate and reorient the palatal
muscles without elevating mucoperiosteal flaps from
the hard palate. Some surgeons feel that this proce-
dure can lengthen the palate by 20–30%. It has also
been proposed that the double-opposing Z-plasty
results in improved speech production7,8; however,
it may lead to increased fistula formation.9 Some
authors state that the Von Langenbeck procedure
should be used to repair incomplete clefts of the sec-
ondary palate when there is no involvement of the
lip or ­alveolus.10 This technique reconstructs the cleft
without associated palatal lengthening. As such, it
may lead to a shortened soft palate with hyperna-
sal speech.5 V-Y pushback (Veau-Wardill-Kilner) is
a variation of the Von Langenbeck procedure. It is
frequently used for incomplete clefts involving the
secondary palate. Some surgeons state it should be
employed when there is decreased mobility of the soft
palate or when lengthening of the palate is required.3
OPERATIVE TECHNIQUE
Commonly used instruments are listed in Table 12.1.
The first operative steps are similar for each
procedure:
1. The surgeon should be positioned at the head
of the table.
2. Place a shoulder roll to hyperextend the
patient’s neck.
3. Place the Dingman mouth gag.
4. Perform procedures with surgical loupes to
enhance visualization.
5. Make the preoperative markings.
 Operative technique  113

Incisive foramen
Dental arch
Intermaxillary suture

Palatine process of maxilla

Palatine foramen

Hamulus

Tensor palatini

Levator palatini

Figure 12.1  Normal anatomy and cleft anatomy.

Table 12.2  Veau classifications of clefting3,4

Veau classification Description of cleft Widely used operative techniques

Class I Incomplete cleft of soft palate only Furlow repair
Class II Cleft of soft and hard palate, but Hard palate: Von Langenbeck or V-Y
limited to secondary palate pushback
Soft palate: Furlow repair
Class III Complete unilateral cleft of both Hard Palate: Two-flap palatoplasty
lip and palate (involving both technique (Von Langenbeck or V-Y
primary and secondary palates) pushback)
Soft palate: Furlow repair palate closure
Class IV Complete bilateral cleft of both lip Hard palate: Two-flap palatoplasty
and palate; the premaxilla is technique (Von Langenbeck or V-Y
suspended from the nasal pushback); may need Vomer flap for
septum closure of nasal mucosal layer
Soft palate: Furlow repair
Source: Hardesty RA, Punjabi AP. Classification and anatomy of cleft palate. In: Mathes SJ. Plastic Surgery. 2nd ed.
Philadelphia, PA: Saunders/Elsevier; 2005:55–67; Van Aalst JA, Kolappa KK, Sadove M. Plast Reconstr Surg.
2008;121(1 Suppl):1–14.
114  Cleft palate repair
6. Infiltrate with 0.5% lidocaine and 1:200,000
epinephrine using a 23-gauge needle along
the preoperative markings until the tissue
blanches. Do not directly inject in the region
of the greater palatine vascular pedicle. Always
aspirate to ensure that there is no intravascular
administration.
The Furlow double-opposing Z-plasty
PREOPERATIVE MARKINGS
A Z marking should be made on the oral palatal
surface with angles of approximately 60°. Lateral
limbs of the Z should extend to the hamuli so that
one of the lateral limbs lies along the hard palate’s
posterior margin. Mark either side of the cleft mar-
gin to 4–5 mm before the tip of each hemiuvula
(Figure 12.2a).
INTRAOPERATIVE DETAILS
1. A Z incision is made in the oral mucosa with
angles of approximately 60°. Wider clefts
will require more obtuse angles for adequate
mobilization of flaps.1
2. Lateral limbs of the Z on the oral mucosa
should extend to the hamuli so that one of the
lateral limbs lies along the posterior margin of
the hard palate (Figure 12.2a).
3. Begin dissection by carefully incising the muco-
sal edges of the cleft with a #15 blade surgical
scalpel so that there is a near equal amount
of mucosa allocated to each side. Commonly,
there is a distinct junction that exists between
the nasal and oral mucosa at the most posterior
portion of the soft palate cleft margin.11
4. Extend the incision along the cleft margin
anteriorly and elevate the mucoperiosteum
of the hard palate, taking care not to damage
this tissue at the cleft margin. This will be
utilized for later closure.
5. Elevate the posterior oral flap by deepening
the lateral incisions as well as the incisions
along the cleft margin. This maneuver will
also elevate the palatal muscle within the flap
(Figure 12.2b).
6. Underlying nasal mucosa has a bluish appear-
ance and must not be injured or torn during
the dissection of the palatal muscles.
7. Use curved nasal scissors to carefully separate
the palatal muscle from its bony insertion and
from the nasal mucosa.
8. Reflect the flap and incise the palatal
aponeurosis.
9. The myomucosal flap is now free to be placed
across the cleft.
10. Elevate the base of the anterior oral m ­ ucosal
flap and mobilize it from the area of the
greater palatine foramen, taking great care
not to lift the muscle with it.
11. Oral flaps are ready to be retracted to expose
the nasal layer (Figure 12.2b).
12. Because the nasal Z-plasty is created in mir-
ror image to the oral Z-plasty, its posterior
flap, on the side of the palate where the oral
flap contained only mucosa, should contain
the muscular portion of the tensor-levator
­aponeurosis11 (Figure 12.2c).
13. Cut the lateral limb of the posterior nasal
Z-plasty along the hard palate margin, leaving
2 mm of nasal mucosa as an edge for sutures
to be placed. This incision is important
because it will free the palatal aponeurosis
and will allow the posterior muscle flap to
move across the cleft.
14. Incise the nasal mucosa and elevate the
­a nterior nasal flap. When making the two
lateral incisions of the nasal Z-plasty, extend
each incision to the lip of the eustachian
orifice.
15. The posterior nasal flap (containing nasal
mucosa and muscle) is placed across the
cleft posterolaterally and secured to the
lateral recess in the palatopharyngeal t­ issue
with an absorbable suture. The anterior
nasal flap (containing only mucosa) is
moved a­ nteromedially and secured to
the p­ alatal shelf mucosa using another
­absorbable suture (i.e., 4-0 chromic)
(Figure 12.2c).
16. Uvular tags are united with absorbable
suture.
17. With the flaps transposed across the cleft,
suture the anterior nasal mucosal and
posterior nasal myomucosal flaps together
(Figure 12.2c).
18. The oral myomucosal flap is positioned
posterolaterally and sutured at the level of
the hamulus, using either a 4-0 Monocryl®
(Ethicon, Somerville, NJ) or Vicryl® (Ethicon)
suture.
19. The oral mucosal flap is inset and sutured to
the hard palate margin.
 Operative technique  115

Anterior nasal
flap

Posterior
nasal flap

(a)   (b)

Anterior flap

Posterior flap

(c)   (d)

Figure 12.2  Furlow double-opposing Z-plasty. (a) Preoperative markings. (b) Elevation of anterior
flap (oral mucosa only) and posterior flap (containing palatal muscle). (c) Closure of the anterior nasal
mucosa flap and the posterior nasal myomucosal flap. (d) Closure of oral mucosal flaps.
116  Cleft palate repair
20. Place two 3-0 Vicryl sutures through the nasal
and oral layers to secure the flaps.
21. Bring the hard palate mucoperiosteum into
a horizontal plane and close with horizontal
mattress sutures (Figure 12.2d).
22. Oral Z-plasty may require a back cut at
the end of the lateral limbs, taking great
caution not to injure the greater palatine
vessels.
The Von Langenbeck procedure
PREOPERATIVE MARKINGS
Mark from 1 cm beyond the hamulus bilaterally,
posterior to the maxillary tuberosity,12,13 curv-
ing the markings anteromedially within 0.5 cm
of the alveolar cleft if there is a complete cleft lip
and ­palate or 1 cm in front of the most anterior
­portion of the cleft in a cleft palate alone.9 Mark
along the cleft margin, starting at the anterior
aspect of the cleft moving posteriorly toward each
hemiuvula. Each marking should be adjacent to
the cleft margin.
Lateral incision
Cleft margin
incision
Hemiuvula
(a)
Figure 12.3  Von Langenbeck palatoplasty. (a) Incisions. (b) Elevating the mucoperiosteal flap through
the lateral incision.
INTRAOPERATIVE DETAILS
1. Using a #15 scalpel blade on a long handle,
incise the medial incisions along the cleft
margin, beginning at the anterior aspect of
the cleft and moving posteriorly toward each
hemiuvula. The incision should be approxi-
mately 1 cm lateral to the cleft margin to assist
with nasal mucosal dissection and closure
(Figure 12.3a).
2. If an alveolar cleft is not present, the i­ ncision
should extend 1 cm anterior to the most
anterior aspect of the cleft. If it is present, the
incision should extend within 0.5 cm of the
cleft margin.13
3. Using an angled Beaver® (Waltham, MA)
blade (or ear, nose, and throat [ENT] tym-
panostomy blade), incise along the alveolar
margin. Palpate the hamulus posterior to the
maxillary tuberosity and start the incision
1 cm beyond this point. Curve anteromedi-
ally through the junction of the palatal and
­gingival mucosal membranes. The incision
should come to within 0.5 cm of the alveolar
Lateral
incision
Cleft margin
incision
  (b)
(Continued)
 Operative technique  117

Suturing nasal mucosa

Suturing oral
mucosa

(c)   (d)

Relaxing incisions

(e)

Figure 12.3 (Continued)  Von Langenbeck palatoplasty. (c) Dissecting the levator palatine muscle.
(d) Closure of the palate. (e) Completion of procedure with relaxing incisions. Surgicel Nu-Knit can be
placed on raw bony surfaces.
118  Cleft palate repair
cleft if there is a complete cleft lip and palate
and to 1 cm in front of the most anterior
­portion of the cleft in an isolated cleft palate.
4. Deepen the incision using an angled Beaver
blade and begin elevation of the mucoperios-
teal flaps.
5. Insert a Kleinert Kutz periosteal eleva-
tor into the lateral incision 1 cm anterior
to the m ­ axillary tuberosity and elevate a
bipedicled, full-thickness, mucoperiosteal flap
­anteromedially (Figure 12.3b).
6. Reinsert the Kleinert Kutz periosteal
­elevator into the lateral incision poste-
rior to the ­maxillary tuberosity, pointing
­posteromedially toward the uvula, and elevate
the soft palate tissue.
7. Insert the Obwegeser periosteal elevator ante-
rior to the maxillary tuberosity to complete
elevation of the mucoperiosteal flap from the
palatal shelf to the edge of the cleft, taking
care not to blindly dissect the greater palatine
neurovascular bundle. This maneuver sepa-
rates the oral mucoperiosteal flap from the
nasal mucosa and palatal bone.
8. The greater palatine neurovascular bundle
should be exposed on the underside of the flap
and can be traced to its emergence from the
nasopalatine foramen. Further dissection of
the remaining fibrous attachments may be car-
ried out with scissors within the subperiosteal
plane.
9. Repeat steps 5–8 on the opposite side of the
palatal shelf.
10. Elevate the nasal mucosa anteriorly off the
nasal side of the hard palate using the angled
Beaver blade and Obwegeser elevator.
11. The exposed levator palatini muscle bundle
is then grasped with forceps just posterior to
the hard palate, and its insertion into the hard
palate is divided (Figure 12.3c).
12. Dissect the muscle bundles on the cleft
bilaterally until they can be freely mobilized
posteriomedially to overlap transversely.
13. Close the nasal mucosa layer with simple
sutures using either 4-0 sutures, starting from
the anterior end of the cleft and moving poste-
riorly toward the uvula (Figure 12.3d).
14. Levator muscles are sutured in the midline
using 4-0 absorbable sutures, incorporating
the oral mucoperiosteal flap as well as the
levator musculature.
15. Oral mucoperiosteal flaps are closed with
4-0 chromic sutures (Figure 12.3e).
16. Exposed bony palate is covered with Surgicel
Nu-Knit® (Ethicon).
17. To obtain additional length and mobilization
of the palatal flaps, multiple procedures can
be performed to generate tissue laxity and
permit movement of the flaps toward m ­ idline.
The levator tendon can be released and
divided. Also, the neurovascular bundle can
be dissected out of the nasopalatine foramen,
and the foramen can be enlarged by using a
2-mm chisel at the posterior bony aspect of the
foramen. Ensure protection of the neurovascu-
lar bundle prior to performing this p­ rocedure.
The hook of the hamulus can be exposed and
fractured with a 2-mm osteotome. Finally, the
incision can be extended into the posterior
pharynx and the tonsillar fossa.
V-Y palatal pushback procedure
PREOPERATIVE MARKINGS
Markings begin at the most anterior portion of the
cleft and continue to the right and left. Extend each
marking anterolaterally to a point just medial to
the alveolus. If the cleft itself represents the verti-
cal limb of the letter Y, then each of these mark-
ings should represent the diagonal limbs. Continue
each marking from most anterior tip of each diago-
nal limb posteriorly along the alveolar ridge to a
point 1 cm posterior to the ridge, ending at the
pterygomandibular raphe. Finally, mark the cleft
margin on both sides of the cleft (Figure 12.4a).
INTRAOPERATIVE DETAILS
1. Make incisions using a #15C scalpel blade
bilaterally along the cleft margin, exposing the
junction between the oral and nasal mucosal
layers.
2. Using a #15C scalpel blade, make two inci-
sions in the oral mucosa along the previously
marked areas to the right and left of the
most anterior part of the cleft. Each incision
will extend anterolaterally just medial to
the lingual aspect of the alvelous. If the cleft
represents the vertical limb of the letter Y,
then each of the incisions should represent
the diagonal limbs (Figure 12.4a).
3. Using a #15C scalpel blade, make incisions
bilaterally along the lingual aspect of the

alveolar ridge extending from the most
anterior tip of each diagonal limb incision to
a point 1 cm posterior to the alveolar ridge,
ending at the pterygomandibular raphe
(Figure 12.4a).
4 . Deepen the incisions using an angled Beaver
blade (or ENT tympanostomy blade) to
begin dissection of the oral mucoperisoteal
flaps.
5. Use a Kleinert Kutz periosteal elevator to
elevate the anterior and posterior oral muco-
periosteal flaps bilaterally. The posterior flaps
are elevated to the posterior aspect of the hard
palate, taking care not to injure the greater
palatine neurovascular bundles.
6. The Obwegeser periosteal elevator is used to
complete elevation of the oral mucoperiosteal
flaps.
7. Use the angled Beaver blade to elevate the
mucoperiosteum of the nasal floor.
Anterolateral
incisions
(a)
Figure 12.4  V-Y pushback palatoplasty. (a) Incisions. The anterolateral incisions represent the d
limbs of the Y. (b) Use the angled Beaver blade to elevate the nasal mucosa and to incise the nasal
mucoperiosteal flap. Incisions indicated by dashed lines.
Operative technique  119
8. At a distance of one-third the palatal length
from the posterior end of the palate, use the
angled Beaver blade to incise the nasal muco-
periosteum flap in a lateral direction on either
side of the cleft. This will allow the soft palate
to move more posteriorly while still covered by
the nasal mucosal membrane (Figure 12.4b).
9. Dissect the palatal musculature free from
the nasal and oral layers as well as from the
hamulus.
10. While remaining superior to the tensor pala-
tine aponeurosis, make a 1-cm cut along the
lateral nasopharyngeal mucosal membrane,
leaving the soft palate attached anteriorly
only by the greater palatine vessels, free from
the restricting nasal mucosal layer and from
the palatal muscles14 (Figure 12.4c, top).
11. Place a 2-mm chisel posterior to the palatine
vessels, angled 45° and perpendicular to
the palate edge. Gently tap the chisel while
  (b)
­ iagonal
(Continued)
120  Cleft palate repair

Closed muscle layer

(c)   (d)

Sutures

Relaxing incision
with exposed
bone

(e)

Figure 12.4 (Continued)  V-Y pushback palatoplasty. (c) Top and bottom, dissect the tensor palatini off
the hamulus. Incise the lateral nasopharyngeal mucosal membrane toward the alveolus (not shown).
This will free the soft palate from the nasal mucosal layer. A 2-mm chisel is used to break the posterior
bony aspect of the nasopalatine foramen with protection of the neurovascular bundle. (d) Closure of
the nasal mucosa, leaving two sutures untied. (e) Completion of procedure with relaxing i­ncisions.
SURGICEL NU-KNIT can be placed on raw bony surfaces.

protecting the neurovascular bundle and
break a triangular portion of the posterior
aspect of the foramen to allow the posterior
palatal flaps to transpose posterior to their
origin (Figure 12.4c, bottom).
12. Bring the nasal mucosal flaps together
at the midline of the palate and close
with interrupted 4-0 chromic sutures,
leaving two sutures untied for later
­i ncorporation into the palatal flaps
(Figure 12.4d).
13. Nasal mucosa that was moved posteriorly
should be secured to the soft palate using
4-0 chromic sutures in a horizontal mattress
fashion (Figure 12.4d).
14. Approximate the anterior mucoperiosteal flap
with the posterior palatal flaps with 3-0 chro-
mic sutures in an interrupted fashion. The two
nasal mucosa sutures that were left untied can
be incorporated into this suture line in a mat-
tress fashion.
15. Close the nasal layer of the soft palate with
interrupted 5-0 chromic suture. Approximate
the muscles using 3-0 chromic sutures in
a mattress fashion. Finally, close the oral
mucosa with interrupted 5-0 chromic suture14
(Figure 12.4e).
16. The denuded portions of the palatal bone are
covered with Surgicel Nu-Knit.
17. To obtain additional length and mobiliza-
tion of the palatal flaps, multiple procedures
can be performed to generate tissue laxity
and permit movement of the flaps toward
midline. The levator tendon can be released
and divided. Also, the neurovascular bundle
can be dissected out of the nasopalatine fora-
men, and the foramen can be enlarged using
a 2-mm chisel at the posterior bony aspect of
the foramen. Ensure protection of the neu-
rovascular bundle prior to performing this
procedure. The hook of the hamulus can be
exposed and fractured with a 2-mm osteo-
tome. Finally, the incision can be extended
into the posterior pharynx and the tonsillar
fossa.
POSTOPERATIVE CARE
A 3-0 silk suture should be placed in a through-
and-through fashion in the anterior portion of
the tongue for retraction in the event of airway
CPT Coding  121
difficulties.5 The patient should be on a liquid-only
diet; if oral intake is insufficient, the patient should
remain on intravenous fluids for 1 to 3 days. If the
patient is older and has dentition, a 1.5% peroxide
rinse should be used after all meals.5 It is impor-
tant that the patient not use toothbrushes, straws,
or oral t­hermometers, or have oronasal suction
performed by an untrained individual. Older
patients are advised not to open their mouths wide
or chew food as it may interfere with the repair.
Infants should be fed with a red rubber cath-
eter and syringe. Arm restraints may be needed
for infants to prevent self-inflicted trauma and
thumb-sucking, which may damage the repair.15
Postoperative analgesia in the form of a rectal sup-
pository may be given to infants if needed. Most
patients can be discharged home approximately
24  hours after surgery8 and should be seen for
­follow-up 1 week later.14
NOTES
Prophylactic antibiotics are unnecessary in healthy
patients.1
If a cleft palate is associated with a Pierre
Robin sequence, extra care should be taken to
maintain the airway during surgery.6 The sur-
gery is usually performed later in life, at around
18 months.
Cleft repair may be contraindicated in patients
with permanent impairments, such as neurologic
conditions, who will never be able to ingest food
orally and who will never speak regardless of cleft
repair. In addition, patients who have significant
cardiopulmonary conditions may not be able to
tolerate anesthesia, thus contraindicating cleft
repair.1
CPT CODING
42200 Palatoplasty for cleft palate, soft and/or
hard palate only
42205 Palatoplasty for cleft palate, with closure of
alveolar ridge, soft tissue only
42210 With bone graft to alveolar ridge
42215 Palatoplasty for cleft palate; major
revision
42220 Secondary lengthening procedure
42225 Attachment pharyngeal flap
42226 Lengthening of palate, and pharyngeal flap
42227 Lengthening of palate, with island flap
122  Cleft palate repair
REFERENCES
1. Afifi GY, Kaidi AA, Hardesty RA. In: Evans
GRD, ed. Operative Plastic Surgery.
New York, NY: McGraw-Hill; 2000:479–503.
2. Thorne CH, Bartlett SP, Beasley RW,
et al. Grabb and Smith’s Plastic Surgery.
6th ed. Philadelphia, PA: Wolters Kluwer
Health Lippincott Williams & Wilkins;
2007:201–225.
3. Hardesty RA, Punjabi AP. Classification
and anatomy of cleft palate. In: Mathes SJ.
Plastic Surgery. 2nd ed. Philadelphia, PA:
Saunders/Elsevier; 2005:55–67.
4. Van Aalst JA, Kolappa KK, Sadove M.
MOC-PSSM CME article: n ­ onsyndromic
cleft palate. Plast Reconstr Surg.
2008;121(1 Suppl):1–14.
5. Horsewell BB. Primary palatoplasty: double-
opposing Z-plasty (Furlow technique).
Atlas Oral Maxillofacial Surg Clin N Am.
2009;17:157–165.
6. Marsh JL, Witt PD. Cleft palate deformities.
In: Bentz ML, ed. Pediatric Plastic Surgery.
Stamford, CT: Appleton and Lange;
1998:93–104.
7. Abdel-Aziz M, El-Hoshy H, Naguib N,
et al. Repair of submucous cleft palate
with Furlow palatoplasty. Int J Pediatr
Otorhinolaryngol. 2012;76(7):1012–1016.
8. Kapetansky DI. Techniques in Cleft Lip,
Nose, and Palate Reconstruction. New York,
NY: Gower Medical; 1987:89–112.
9. Vander Kolk CA. Cleft palate. In: Vander
Kolk C, ed. Plastic Surgery: Indications,
Operations and Outcomes. Vol. 2. St. Louis,
MO: Mosby, 2000: Chap. 54.
10. Leow AM, Lo LJ. Palatoplasty: evolution
and controversies. Chang Gung Med J.
2008;31(4):335–345.
11. Furlow LT. Cleft palate repair by double
opposing Z-plasty. Plast Reconstr Surg.
1986;78(6):724–738.
12. Smith KS, Ugalde CM. Primary pala-
toplasty using bipedicle flaps (modi-
fied von Langenbeck technique). Atlas
Oral Maxillofac Surg Clin North Am.
2009;17(2):147–156.
13. Trier WC, Dreyer TM. Primary von
Langenbeck palatoplasty with l­evator
reconstruction: rationale and t­ echnique.
Cleft Palate J. 1984;21(4):254–262.
14. Yules RB. Atlas for Surgical Repair of
Cleft Lip, Cleft Palate, and Noncleft
Veloparyngeal Incompetence. Springfield,
IL: Thomas; 1971.
15. Agrawal K. Cleft palate repair and
variations. Indian J Plast Surg.
2009;42(Suppl):S102–S109.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 13
Orbital floor fracture

URMEN DESAI, WILLIAM BLASS, AND HENRY K. KAWAMOTO

Introduction 124 Preoperative markings 129

Transconjunctival approach to orbital floor Intraoperative details 129
fracture repair 128 Postoperative care 130
Preoperative markings 128 CPT coding 130
Intraoperative details 128 Suggested readings 131
Cutaneous approach to orbital floor fracture Acknowledgment 131
repair 129

INDICATIONS

1. Three primary surgical indications for the
repair of fractures of the orbital floor are:
a. Orbital floor fractures greater than 2 cm
or >50% of surface area of the orbital floor
b. Enophthalmos >2 mm
c. Incarceration or entrapment of extraocular
muscles
2. There are currently a number of surgical
approaches to the orbital floor. Two of the
most commonly used techniques are:
a. Pre-septal transconjunctival approach with
or without canthotomy
b. Cutaneous approach

Table 13.1  Special equipment

0.5% topical ophthalmic tetracaine hydrochloride
1% lidocaine with 1:100,000 epinephrine
30-gauge needle
Lubricating ophthalmic ointment
Needle-tip electrocautery
5-0 nylon suture
6-0 fast-absorbing gut suture
Desmarres retractor
Small blunt-tip dissection scissor
Cotton-tip applicators

123
124  Orbital floor fracture

INTRODUCTION transmission of a direct blow to the infraorbital rim

Isolated orbital floor fractures (blowouts) are often
the result of impact injury to the globe resulting in
a sudden increase in intraorbital hydraulic ­pressure.
This kinetic energy is transmitted in an inferior
and medial vector to the orbital floor (hydraulic
theory) (Figure  13.1). Alternatively, the posterior
causes buckling and resultant fracture of the orbital
floor (buckling theory) (Figure 13.2). Fractures of the
orbital floor can increase the ­volume of the orbit
with resultant enophthalmos and hypoglobus. These
can be highlighted on preoperative (Figure 13.3a–c)
and postoperative (Figure 13.4a–c) computed tomo-
graphic (CT) scan imaging. In addition, the inferior

Figure 13.1  Transmission of kinetic energy in an inferior and medial vector to the orbital floor
­(hydraulic theory).

Figure 13.2  Posterior transmission of a direct blow to the infraorbital rim causing buckling and
­resultant fracture of the orbital floor (buckling theory).
 Introduction 125

(a)

(b)

Figure 13.3  Preoperative CT scan imaging of a left orbital floor fracture in (a) coronal, and (b) sagittal
views. (Continued)
126  Orbital floor fracture

(c)

Figure 13.3 (Continued)  Preoperative CT scan imaging of a left orbital floor fracture in (c) axial views
highlighting the increase in volume of the orbit with resultant enophthalmos and hypoglobus.

(a)

Figure 13.4  Postoperative CT scan imaging of placement of titanium mesh for a left orbital floor
­fracture in (a) coronal view. (Continued)
 Introduction 127

(b)

(c)

Figure 13.4 (Continued)  Postoperative CT scan imaging of placement of titanium mesh for a left
orbital floor fracture in (b) sagittal, and (c) axial views highlighting the resolution of preoperative
enophthalmos and hypoglobus.
128  Orbital floor fracture
rectus or periorbital soft tissue can become entrapped
within the fracture line, resulting in restriction of
extraocular eye movements. Table 13.1 indicates the
special equipment used to surgically manage this
injury.
TRANSCONJUNCTIVAL APPROACH
TO ORBITAL FLOOR FRACTURE
REPAIR
Preoperative markings
1. A marking pen is used to make a surgical
markings 2 mm inferior to the lower border of
the tarsal plate (Figure 13.5).
2. The medial extent of the markings should be
in line with the inferior punctum.
3. The lateral extent of the markings should
be several millimeters medial to the lateral
canthus.
Intraoperative details
1. Two drops of 0.5% tetracaine hydrochloride
are instilled into each inferior fornix, fol-
lowed by 1 mL of 1% lidocaine with 1:100,000
Figure 13.5  Preoperative marking for a pre-­
septal transconjunctival approach to the orbital
floor. A marking pen is used to make a planned
incision 2 mm inferior to the inferior border of
the tarsal plate.
epinephrine injected into the lower lid
­conjunctiva using a 30-gauge needle.
2. A needle-tip electrocautery is used to make a
transconjunctival incision as previously marked.
3. A 5-0 nylon suture is placed through the
conjunctiva closest to the fornix to retract the
posterior lamella over the cornea to serve as a
corneal protector. Retraction with a mosquito
hemostat held onto the patient’s head wrap
holds the suture under tension (Frost retention
suture). Alternatively, a corneal protector can
be used to prevent ocular trauma (Figure 13.6).
4. Simultaneous eversion of the lower eyelid with
a Desmarres retractor and gentle pressure on
the globe produces a bulge of orbital fat which
helps guide the dissection (Figure 13.7).
5. The dissection is carried down through the
lower lid retractors and then into the plane
between the orbicularis oculi and orbital sep-
tum (pre-septal) inferiorly to the periosteum
of the orbital rim. Next, the periosteum at the
medial aspect of the infraorbital rim is incised
and the incision is continued laterally. The
dissection is then continued in a subperios-
teal plane to expose the limits of the fracture
along the orbital floor (Figure 13.8).
Figure 13.6  A corneal protector can be placed to
avoid any ocular trauma.
 Cutaneous approach to orbital floor fracture repair  129

the bony defect, preventing malpositioning

of the soft tissue and restoring pre-injury
anatomic volume. A canthotomy may be
needed to adequately place the implant into
the orbital floor.
8. The conjunctival incision can then be reap-
proximated with or without need for suture
closure.
9. A forced duction test is then performed to
confirm mobility of the extraocular muscles.

CUTANEOUS APPROACH TO
ORBITAL FLOOR FRACTURE REPAIR
Preoperative markings
1. An incision is marked in a natural rhytid
Figure 13.7  Eversion of the lower eyelid with a beneath the tarsal plate.
Desmarres retractor and gentle pressure on the
2. The medial extent of the marking lies 1 mm
globe produces a bulge of orbital fat which helps
to guide the dissection.
lateral to the inferior punctum to avoid poten-
tial injury to the interior canaliculus.
3. The lateral extent of the marking lies 8–10 mm
lateral to the lateral canthus, blending into a
natural periorbital rhytid.

Intraoperative details
1. 1 mL of 1% lidocaine with 1:100,000 epineph-
rine is injected along the surgical markings
down to the infraorbital rim using a 30-gauge
needle.
2. A #15 blade is used to make a skin incision
until the level of the lateral canthus. Lateral
to this point, the incision is carried down
through the orbicularis oculi muscle.
3. A small, blunt-tip dissection scissor is used to
dissect in a submuscular plane in a lateral-to-
medial direction.
Figure 13.8  Dissection is performed through 4. A 5-0 nylon or silk suture is then placed
the lower lid retractors and then into the plane through the gray line lateral to the limbus
between the orbicularis oculi and orbital septum for countertraction and to protect the globe
(pre-septal) inferiorly to the periosteum of the (Frost retention suture).
orbital rim. The dissection is then continued in a 5. Blunt dissection using a combination of a
subperiosteal plane to expose the limits of the cotton-tip applicator and a small blunt-tip
fracture along the orbital floor. dissection scissor is carried out to develop
a skin-muscle flap down to the level of the
6. The herniated fat and soft tissue are then infraorbital rim.
retracted from the maxillary sinus in a 6. Next, the periosteum is incised at the anterior
“hand-over-hand” fashion. border of the infraorbital rim, starting medi-
7. An autologous bone graft or alloplastic ally and continuing laterally. The dissection
implant is then placed to completely cover is then continued in a subperiosteal plane to
130  Orbital floor fracture
expose the limits of the fracture along the
orbital floor.
7. The herniated fat and soft tissue are then
retracted from the maxillary sinus in a
“­hand-over-hand” fashion.
8. An autologous bone graft or alloplastic
implant is then placed to completely cover the
bony defect, preventing malpositioning of the
soft tissue and restoring pre-injury anatomic
volume.
9. A forced duction test is then performed to
confirm mobility of the extraocular muscles.
10. The inferior skin-muscle flap is then redraped,
and a 6-0 fast-absorbing gut suture is used to
reapproximate the skin incision in running
fashion.
11. Antibiotic ointment is then applied to the
subciliary skin incision.
Postoperative care
1. Head of bed at 45°.
2. Cold compresses to reduce immediate post­
operative edema for 24–48 hours.
3. Close observation in a dimly lit room for
any indication of retrobulbar hematoma for
at least 1–2 hours postoperatively; only dis-
charge after a thorough visual examination is
performed.
4. Ocular lubrication with artificial tears and
nighttime lubrication with ophthalmic anti­
biotic ointment.
5. Strict instructions to limit physical activity for
2 weeks postoperatively.
6. Monitor closely on follow-up examination
for any signs of development of ectropion,
scleral show, or any changes in lid contour or
malposition.
KEY POINTS
●● A thorough preoperative evaluation by
an ophthalmologist is essential if visual
acuity is decreased and retinal damage
or optic nerve injury is suspected.
●● Meticulous hemostasis is crucial for
reducing the chance of developing a
postoperative retrobulbar hematoma.
●● Complications of orbital floor repair
include:
●● Retrobulbar hematoma: Vascular
injury during the operation with
retraction of a vessel into the retro-
bulbar space can lead to this poten-
tially catastrophic complication.
This would present with proptosis,
chemosis, and pain that becomes
progressively worse. Loss of visual
acuity can be indicative of optic
nerve ischemia. This complication
typically occurs within the first 4 to
6 hours postoperatively and requires
prompt opening of incisions, saline
compresses, intravenous treatment
with mannitol, diamox, and decad-
ron, controlling hypertension and
any coagulopathies.
●● Ectropion: Postoperative scleral
show can be due to edema or weak-
ness of the orbicularis oculi muscle,
and resolves with edema resolution
and muscle reinnervation.
●● Corneal injury: Lubrication is the best
measure to prevent corneal injury.
●● Dry eyes: Injury to the lacrimal
gland and postoperative edema can
lead to dry eyes.
●● Epiphora: Common postoperatively
during the first 48 hours due to
edema or temporary decrease in
muscle one.
●● Extraocular muscle injury: The infe-
rior oblique muscle is vulnerable to
injury during dissection of fat com-
partments in the lower lid. Injury to
this muscle would present as diplopia
on upward and lateral gaze.
CPT CODING
21385 Open treatment of orbital floor ­blowout
­fracture; transantral approach (Caldwell-Luc-
type operation)
21386 Open treatment of orbital floor blowout
fracture; periorbital approach

21387 Open treatment of orbital floor blowout
fracture; combined approach
21390 Open treatment of orbital floor blowout
fracture; periorbital approach, with implant
21395 Open treatment of orbital floor blowout
fracture; periorbital approach with bone graft
(includes obtaining graft)
21400 Closed treatment of fracture of orbit, except
blowout; without manipulation
21401 Closed treatment of fracture of orbit, except
blowout; with manipulation
21406 Open treatment of fracture of orbit, except
blowout; without implant
21407 Open treatment of fracture of orbit, except
blowout; with implant
21408 Open treatment of fracture of orbit,
except blowout; with bone grafting
(includes ­obtaining graft)
Acknowledgment 131
SUGGESTED READINGS
Desai U, Roeder R, Lemelman B, Thaller SR.
Maxillofacial Trauma, in Current Therapy in
Trauma and Critical Care, 2nd ed. Mosby,
2015 (in press).
Gart MS, Gosain AK. Evidence-Based Medicine:
Orbital Floor Fractures, Plast Reconstr Surg.
Dec, 134(6):1345–55, 2014.
Rodriguez ED, Dorafshar AH, Manson PN, Facial
fractures, in Plastic Surgery, 3rd ed., Neligan
PC, Elsevier Canada, 2012.
ACKNOWLEDGMENT
We are grateful for the artistic contributions of
Elan Horesh and Kriya Gishen.
 14
Mandible fracture management

LARRY H. HOLLIER JR., AMY S. XUE, AND EDWARD BUCHANAN

Introduction 133 Closure 136

Preoperative markings 134 Postoperative care 136
Intraoperative details 134 Notes 138
Fractures of the mandibular symphysis or body 134 CPT coding 138
Fractures of the angle 136 Suggested readings 138
Subcondylar fractures 136

INDICATION

All displaced mandible fractures

Table 14.1  Special equipment

24- and 26-gauge wire
Erich arch bars
Electric or gas-powered drill system
Mandibular plating system, including plates
accommodating 2.0- and 2.4-mm screws
Antibiotic irrigation consisting of:
Normal saline 500 mL
Polymyxin or bacitracin 500,000 units
Cottonoids soaked in dilute epinephrine
solution (1:100,000 dilution)

INTRODUCTION on internal fixation of the fractures followed by

The treatment of mandibular fractures can be
challenging due to the complexity of mandibu-
lar shape and the various sites at which fractures
can occur. Although the vast majority of man-
dible fractures can be successfully treated by up
to a 6-week period of maxillomandibular fixa-
tion, most contemporary management focuses
immediate function. The focus of all surgery for
these injuries should be on restoring the pre-
injury occlusion and establishing complete bone
union. Table 14.1 indicates the equipment needed
for these surgeries.
Preoperative examination should include a thor-
ough assessment of occlusion, the dentition, and
fracture mobility with bimanual manipulation.

133
134  Mandible fracture management
The  function of the mental nerve should be
assessed  as well, as any fracture crossing the infe-
rior  alveolar canal can result in neurosensory
deficits  in the lower  lip and chin. Although  com-
puted tomographic (CT) imaging is standard  in
facial fractures, most mandibular injuries are ade-
quately assessed with a panoramic x-ray (Panorex)
(Figure 14.1) and an anteroposterior (AP) view.
PREOPERATIVE MARKINGS
Preoperative marking depends entirely on the
approach to the fracture. Simple fractures are best
treated through an intraoral incision in the gingi-
vobuccal sulcus. Complex fractures are often best
treated through an external incision in the neck.
This should be marked approximately two finger-
breadths below the inferior mandibular border.
This prevents the incision from riding up to the
level of the cheek when the patient is upright.
INTRAOPERATIVE DETAILS
1. At the beginning of the procedure, the incision
should be made and the fracture site exposed and
grossly reduced. Most fractures of the mandible
can be accessed through a vestibular incision.
2. When using an intraoral incision, great care must
be taken to avoid injury to the mental nerve.
In addition, an adequate cuff of mucosa must be
left attached to the mandible to allow closure.
When using an extraoral incision, once the level
of the platysma is reached, a hemostat should be
used to spread deep to it before resecting with the
eletrocautery to avoid damaging the marginal
branch of the facial nerve. Usually, this can be
Figure 14.1  Panorex is often adequate to assess the location and extent of mandibular fracture. This
patient sustained a left angle fracture (arrows) with an impacted molar, which required extraction.
found crossing the mandibular border at the level
of the facial artery and vein.
3. Cottonoids soaked with dilute epinephrine
solution are placed in the operative site and
attention is turned to the arch bars. The frac-
ture should be reduced at this point.
4. Arch bars should be applied on the upper and
lower dentition using 26-gauge circumdental
wires from at least the first bicuspid through
the second molar. Generally, the incisors are
not utilized for the wire placement due to con-
cerns regarding potential tooth extrusion.
5. The intermaxillary fixation should be achieved
with either elastics or with wire to reestablish
what appears to be the pre-injury occlusion
(Figure 14.2).
6. Fracture fixation is a secondary goal after
occlusal stabilization. Anatomic reduction of
a mandibular fracture is facilitated by maxil-
lomandibular fixation.
FRACTURES OF THE MANDIBULAR
SYMPHYSIS OR BODY
Anatomically, the fixation of fractures in the man-
dibular symphysis or body is distinct for several
reasons. First, the inferior alveolar neurovascu-
lar canal must be protected from fixation screws.
In  addition, the distance from the tooth roots to
the inferior mandibular border is short, particu-
larly with respect to the canine tooth. Plates and
screws must be placed below this.
1. A drill hole should be placed on either side
of the fracture along the inferior mandibular
border and the bone reduction clamp placed
 Fractures of the mandibular symphysis or body  135

Figure 14.2  Maxillomandibular fixation (MMF) provides temporary stability to ensure pre-injury occlu-
sion prior to internal fixation. This was commonly used in the past as the sole management of man-
dibular fractures; however, current correction techniques focus on internal fixation and early mobility.

Figure 14.3  Parasymphyseal fracture managed with tension band with 2.0-mm screws placed
­monocortically and miniplate with 2.4-mm screws placed bicortically. Maxillomandibular fixation
(MMF) is used for additional stabilization.

here to stabilize the fragments. The bone clamp
should always be placed such that the compres-
sive force is perpendicular to the fracture.
2. A tension band miniplate accommodating
2.0-mm screws should be placed approximately
two crown lengths below the upper mandibular
border to avoid the tooth roots (Figure 14.3). This
is done by drilling the hole closest to the fracture
site on one side with constant saline irrigation.
A 6.0-mm screw is then placed here. An identical
hole is then drilled adjacent to the fracture on the
contralateral side and a 6.0-mm screw placed.
3. Holes are then drilled and screws placed
sequentially, moving peripherally in the
plate. At least two and preferably three screws
should be used on either side of the fracture.
The screws should be approximately 6 mm in
length.
4. The bone reduction clamp should then be
removed and a plate accommodating 2.0- or
2.4-mm screws adapted to the inferior man-
dibular border (Figure 14.3). They should be
applied similarly to the tension band plate, but
with the holes drilled and the screws applied
136  Mandible fracture management
bicortically after measuring hole depth with
a depth gauge. For the most severe fractures,
thicker plates and 2.4-mm diameter screws
(locking) should be used.
5. At this point, the intermaxillary wires or elas-
tics should be removed and the bite checked by
assessing the patient’s wear facets to verify the
pretraumatic occlusion. If the occlusion is off,
the plates should be removed and readapted
prior to reapplication.
FRACTURES OF THE ANGLE
The mandibular angle is a common location
for fracture. Fixation in this type of fracture
requires attention to avoid the inferior alveolar
nerve and to provide a functionally stable fixa-
tion capable of withstanding opposing muscle
forces. Typically, simple angle fractures can be
treated with a single miniplate along the external
oblique ridge.
1. The first step is to decide if the third molar
requires extraction. Injured or grossly diseased
third molars and those interfering with reduc-
tion of the fracture should be extracted prior to
reduction and plate fixation.
2. After maxillomandibular fixation, an inci-
sion is made just lateral to the external
oblique region and the mucosa dissected up
to the mandible, creating a small flap that
will lie over the fixation plate. There is no
need to completely strip the buccal perios-
teum off the fracture site if the occlusion
has been reestablished. This only prolongs
healing time.
3. A miniplate accommodating 2.0-mm
screws isthen bent to lie along the external
oblique line as it transitions from the supe-
rior ­mandibular border to the buccal cortex
(Figure 14.4).
4. A drill hole is placed on the proximal mandib-
ular fragment, and a 6- or 8-mm screw is used
to affix the plate.
5. Again, the drill is used to create a monocortical
hole distal to the fracture on the buccal cortex,
and a 6- or 8-mm screw is used.
6. The remaining holes are drilled and filled with
screws as described previously.
7. The intermaxillary fixation is removed after
fixation, and the bite is assessed.
8. An extraoral approach may be ­necessary
for comminuted fractures or those for
which intraoral reduction is impossible
(Figure 14.5).
SUBCONDYLAR FRACTURES
Most subcondylar fractures can be treated with
a period of arch bars and training elastics to
ensure that the patient’s pre-injury bite is rees-
tablished throughout the healing period. Plating
of these fractures is complicated and beyond the
scope of  this chapter. This may, however, be
necessary in certain situations, such as bilat-
eral subcondylar neck fractures associated with
severe midfacial fractures, destroying any ver-
tical frame of reference for reestablishing facial
height.
CLOSURE
Closure is achieved typically with a running 4-0
Vicryl® (Ethicon, Somerville, NJ) suture on a taper
needle or with a 4-0 chromic suture. In the region
of the symphysis, the mentalis muscle should be
resuspended prior to closing the mucosa using
interrupted Vicryl sutures.
POSTOPERATIVE CARE
Postoperatively, the patient should undergo repeat
radiographic evaluation to assess plate and screw
locations. Patients are continued on antibiotics for
5 to 7 days and are given instructions for a non-
chew diet and for oral rinses at least three times
a day. The patients may be discharged the day of
surgery assuming pain is under control and they
are able to achieve oral intake.
Patients are typically seen at 1 week postop-
eratively to assess healing of the incision and the
status of their occlusion. Elastics can be used
to help guide the patient’s bite, but their force
should be reduced over time to allow functional
use of the jaw. Should the postoperative course
be uneventful, the patient’s diet is advanced
gradually beginning 6 weeks postoperatively. If
arch bars are used in conjunction with internal
fixation, they should be removed under local
anesthesia or intravenous sedation after 4 to
6 weeks. Generally, removal of plate hardware is
unnecessary.
 Postoperative care  137

Figure 14.4  Mandibular angle fracture (top left) managed with miniplate across the external oblique
ridge (top right). Postoperative Panorex (bottom) showed good approximation and stable fixation of
the fracture site.

Figure 14.5  Mandibular angle fixation using two plates via external approach.
138  Mandible fracture management
NOTES
Both rigid and non-rigid fixation techniques have
been used widely, each with their respective ben-
efits. Rigid internal fixation utilizes either locking
or nonlocking plates to permit immediate return
to full function with primary bone healing and no
callus formation. Non-rigid, or functionally stable,
internal fixation theoretically allows some motion
at the fracture site but leads to secondary bone
healing. The typical example is the Champy tech-
nique (using a single miniplate).
It is useful to consider the load-bearing poten-
tial of the fractured bones. Comminuted fractures
or those with missing bone segments will ben-
efit from load-bearing rigid fixation to withstand
functional forces of the mandible. On the other
hand, load-sharing or functionally stable fixation,
where load is shared between the hardware and the
bone, is adequate for most mandibular fractures
with no comminution or bony defects.
CPT CODING
21454 Open treatment with interdental fixation
21461 Open treatment without interdental
fixation
21454 Open treatment with external fixation
21244 Mandibular staple bone plate
SUGGESTED READINGS
Abdel-Galil, K, Loukota, R. Fractures of the
­mandibular condyle: evidence base and
­current concepts of management. BJOMS
2010;48 (7): 520–526.
Barker DA, Oo KK, Allak A, et al. Timing for
repair of mandible fractures. Laryngoscope
2011;121:1160–1163.
Stacey DH, Doyle JF, Mount DL, et al.
Management of mandible f­ ractures. Plast
Reconstr Surg 2006;117(3):48e–60e.

Zygomatic and zygomaticomaxillary
complex (ZMC) fractures
DAVID E. MORRIS AND MIMIS N. COHEN
Introduction 140
Preoperative markings 142
Reduction of depressed zygomatic arch fracture 142
Open reduction of ZMC fracture 142
Intraoperative details 142
Reduction for isolated arch fracture 142
Open reduction with internal fixation of
ZMC fracture 143
INDICATIONS
1. Functional deficit resulting from coronoid
impingement (limitation in ability to open
mouth)
2. Treatment/prevention of contour deformity
caused by skeletal malposition (malar
Table 15.1  Equipment for open reduction
without fixation of zygomatic arch fracture
(Gillies approach)
Basic soft tissue instruments (#15 blade,
Adson forcep, Senn retractor, needle
driver)
Urethral sound or other long-handled blunt
elevator
Padded eye shield (for postoperative splint)
15
Postoperative details 145
Open reduction for isolated arch fracture
without fixation 145
Open reduction of ZMC fracture 145
CPT coding 145
References 145
projection, alteration in facial width, globe
position) (Figure 15.1)
Table 15.2  Equipment for open reduction with
internal fixation of zygomaticomaxillary
complex fracture
Tray with soft tissue instruments sufficient for
orbital approach and intraoral approaches to
facial skeleton
Carroll-Girard screw
28-gauge wire
Plating system containing 1.5 and 2.0 plating
options with low-profile plates for periorbital
region
Alloplastic implant or instruments to harvest
autogenous bone (rib, calvarium) for orbital
floor reconstruction
139
140  Zygomatic and zygomaticomaxillary complex (ZMC) fractures

INTRODUCTION reconstruction of the orbital floor is often indi-

cated. ZMC fractures may cause deformity in
The zygoma is a spatially complex bone that facial width, orbital rim step-offs, cheek projec-
articulates with the frontal bone, maxilla, tem- tion, and globe position. Medial displacement of
poral bone, and sphenoid. Zygomaticomaxillary the temporal process may cause trismus through
complex (ZMC) fractures that occur with lower-­ impingement on the coronoid.
velocity blunt impact often occur at these articu- Direct impact to the lateral face may cause
lations. Spatially, they displace the ZMC with an isolated depressed zygomatic arch fracture.
minimal comminution (Figure  15.2). Higher- Significant displacement may result in loss of
velocity injuries (e.g., gunshot wounds) often cause ­lateral facial width or trismus.
comminution with more complex fracture pat- Treatment of zygoma fractures is generally:
terns (Figure  15.3). By definition, given the anat- nonoperative (for nondisplaced fractures), reduc-
omy of the zygoma, a ZMC fracture must affect the tion without fixation (for isolated zygomatic
orbital floor or lateral orbital wall. Simultaneous arch fractures) and exploration of the zygoma

(a)

(b)

Figure 15.1  Untreated right zygomaticomaxillary complex (ZMC) fracture. (a) This patient presented
with deformities associated with untreated right ZMC and frontal bone fractures: asymmetric facial
width, posteroinferiorly positioned orbital rim and malar eminence, globe malposition, malposition
of eyelids. (b) Associated computed tomographic (CT) findings.
 Introduction 141

Figure 15.2  Low-energy ZMC fracture. CT findings are typical of those associated with a low-velocity
blow: fractures or separations noted at the suture lines and three-dimensional displacement of the
ZMC as a single segment. In this case, the ZMC is rotated medially and impacted along the zygomati-
comaxillary suture line.

Figure 15.3  High-energy ZMC fracture: comminuted left ZMC fracture due to gunshot wound.
Note foreign body and fracture fragments in the region of the coronoid process.
142  Zygomatic and zygomaticomaxillary complex (ZMC) fractures

and articular processes with open reduction and
internal ­
­ fi xation (ORIF). There remain several
aspects of controversy in the latter t­reatment:
the number of fracture sites that must be explored,
sites requiring fixation for adequate stability,
and ideal surgical incisions to achieve satisfac-
tory exposure. This chapter presents our general
approach,1 representing our interpretation of the
literature.
PREOPERATIVE MARKINGS
Reduction of depressed zygomatic
arch fracture (Figure 15.4)
1. The position of the zygomatic arch and pre-
sumed fracture line is based on a computed
tomographic (CT) scan and gentle palpation.
2. Course of temporal branch of facial nerve is
determined.
3. Course of superficial temporal artery is deter-
mined (by palpation).
4. Avoiding items 2 and 3 above, a 1-cm long inci-
sion is designed within hair-bearing scalp. This
generally originates superior and anterior to
root of the helix of ear or just beyond.
Open reduction of ZMC fracture
Pertinent markings depend on those articular
­processes that will be explored.
1. For exposure at the frontozygomatic suture,
this fracture site can often be palpated. Taking
note of the course of the frontal branch of the
facial nerve and staying anterior to this, a 1-cm
incision is marked parallel with the lateral
orbital rim and directly over the fracture.
Alternatively, an upper eyelid approach can be
utilized.
2. For exposure of the orbital rim, the authors
prefer a lower eyelid approach, placing the inci-
sion within an existing skin crease whenever
possible.
INTRAOPERATIVE DETAILS
Reduction for isolated arch fracture
1. General anesthesia is required.
2. The skin incision line and subcutaneous tissues
are infiltrated with 1% lidocaine containing
1:100,000 epinephrine based on preoperative
markings (see above).
3. Skin is incised and dissection carried through
subcutaneous fat and temporoparietal f­ ascia,
and the glistening white superficial layer of
deep temporal fascia is identified. This is
incised with a #15 blade to expose temporalis
muscle.
4. A urethral sound or blunt elevator is used to
reduce the fracture. The instrument is laid
on the skin, overlying the trajectory from

Figure 15.4  Reduction of isolated zygomatic arch fracture through a Gillies approach. Skin markings
(overlay) are made designating the position of the arch (blue), course of the temporal branch of the
facial nerve (yellow), and by palpation, the superficial temporal artery (red). Avoiding the last two
structures, a 1-cm incision is made anterosuperior to the root of the helix.

incision to just beyond the estimated fracture
site, t­ aking note of the length that must be
advanced to pass the fracture line.
5. An instrument is gently passed just above the
temporalis muscle, hugging the undersurface
of the superficial layer of the deep temporal
fascia until it is past the point of fracture
(Figure 15.4).
6. With steady outward pressure, the sound is
pulled laterally, lifting the depressed arch out-
ward. A single, strong, steady attempt with a
well-placed instrument is preferable to multiple
attempts at manipulation.
7. The incision is irrigated, hemostasis ensured,
then incision is sutured and topical antibiotic
ointment applied.
8. Apply a splint. An elliptical eye shield with
holes and padding along the rim is used. Two
0-nylon sutures are passed percutaneously,
under the reduced arch, and tied over the eye
shield. These are tied firmly but not so that
they cause skin necrosis.
9. Of note, a Keen approach with the incision in
the gingivobucchal sulcus can also be used.
This involves a subperiosteal dissection and use
of a Rowe-Kiley elevator.
Open reduction with internal fixation
of ZMC fracture
1. Based on CT scan, the surgeon determines
which fracture sites are to be explored.
In general, each suture at which displacement
is noted is addressed, the arch is explored
through a coronal approach, only in those
cases of significant displacement and/or
comminution in which position will not
likely be correctable with manipulation from
the anterior approaches. Most commonly
in our experience, the majority of fractures
are explored at these three sites: fronto-
zygomatic suture through direct incision
overlying the suture, intraoral (upper gingi-
vobuccal sulcus), and orbital (lower eyelid or
transconjunctival).
2 . Preparation: This procedure is performed
under general anesthesia with oral intuba-
tion. Preoperative antibiotics are given.
A throat pack is placed. Teeth are brushed
with dilute aqueous Betadine® (Purdue
Products, Stamford, CT) solution. A corneal
Intraoperative details  143
shield is placed. Planned areas of dissection
are infiltrated with lidocaine-containing
epinephrine.
3. The fractures including the orbital floor and
lateral wall are widely exposed subperiosteally
(Figure 15.5). Soft tissue is debrided from the
fracture lines with a small curette.
4 . Careful reference is made to the CT scan
regarding the direction the ZMC must be
translated/rotated to restore correct anatomy,
and the segment is reduced. This is done by
placing an elevator in the maxillary sinus
or hooking it under the anterior aspect of
the zygomatic arch. A Carroll-Girard screw
may be placed through one of the open inci-
sions or through a separate skin incision,
usually into the heavier lateral aspect of the
zygoma, and used as a joystick (Figure 15.6).
Especially for subacute fractures, mobi-
lization may be d ­ ifficult. It is important
to be persistent in mobilization to avoid
undercorrection.
5. Holes are drilled, and a temporary 28-gauge
wire is placed across the frontozygomatic
fracture initially and then at the other sites as
needed to hold the reduction.
6. Each fracture line is inspected to make sure
spatial position of the ZMC is correct at all
articulations. Visualization of the inner align-
ment of the lateral orbital wall is important in
verifying proper reduction.
7. Each of the exposed fracture sites is fixated
with a titanium plate and screws. Temporary
wires are removed after placement of the
plates.
8. The orbital floor is again inspected, and if a
residual defect remains despite appropriate
reduction of the ZMC, then this is recon-
structed using either autogenous bone or an
alloplastic implant (Figure 15.7). A forced
duction test is done preoperatively and prior to
closure.
9. Wound closure: The intraoral incision is
closed with interrupted 3-0 Vicryl® (Ethicon,
Somerville, NJ) suture in a single layer.
Through the lower lid incision, the periosteum
of the orbital rim is resuspended to either its
superior cut edge or to the orbital rim plate
itself. Lower eyelid and frontozygomatic skin
incisions are closed with a fine non-absorbable
suture.
144  Zygomatic and zygomaticomaxillary complex (ZMC) fractures

Figure 15.5  Anterior approaches to treat left ZMC fracture. The typical anterior approaches favored
by the authors are demonstrated: direct incision overlying zygomaticofrontal suture, lower lid incision,
and intraoral (unilateral gingivobuccal sulcus incision).

Figure 15.6  Mobilization and reduction of the zygoma. A Carroll-Girard screw is placed through an
­existing incision or through a separate percutaneous incision into a stable portion of zygoma to ­mobilize it.

Figure 15.7  Orbital floor reconstruction. After the ZMC has been reduced and fixated, the c­ oexisting
orbital floor fracture, if present, is treated. Here, a titanium mesh is placed through the lower lid
­incision that was used to expose the inferior orbital rim.
POSTOPERATIVE DETAILS
Open reduction for isolated arch
fracture without fixation
The patient is instructed to use topical antio­biotic
ointment for 48 hours postoperatively over the
incision and to resume showering/shampooing
the hair 24 hours postoperatively. The splint is
removed 1 week postoperatively.
Open reduction of ZMC fracture
Visual function is examined immediately post­
operatively. A CT scan is obtained within the first
24  hours. Topical antibiotic ointment and oph-
thalmic ointments are prescribed for 48 hours for
skin and periorbital incisions, respectively. The
patient is encouraged to shower starting 24 hours
­postoperatively. With regard to intraoral care, the
patient is placed on a clear liquid diet for 48 hours,
followed by a full liquid diet for 48 hours, then a
soft diet for 1 week. Chlorhexidine mouth rinses
twice per day and warm saltwater mouth rinses
after each meal are prescribed for 1 week. The fron-
tozygomatic and lower eyelid sutures are removed
on the fifth postoperative day.
CPT CODING
The following are the applicable diagnostic and
procedural codes with regard to treatment of
­zygomatic arch and ZMC fractures.2
References 145
21355 Percutaneous treatment of fracture of malar
area, including zygomatic arch and malar
tripod, with manipulation
21356 Open treatment of depressed zygomatic
arch fracture (e.g., Gillies approach)
21360 Open treatment of depressed malar
fracture, including zygomatic arch and malar
tripod
21365 Open treatment of complicated fracture(s)
of malar area, including arch and malar tripod;
with internal fixation and multiple surgical
approaches
21366 Open treatment of complicated fracture(s)
of malar area, including zygomatic arch and
malar tripod; with bone ­grafting (includes
obtaining graft)
REFERENCES
1. Manson, P. Facial fractures. In Stephen
Mathes, ed. Plastic Surgery. Elsevier, 2006.
2. Optum EncoderPro.com Product Suite 2012
software.
 Part     4
Cosmetic

16 Non-surgical facial rejuvenation with neuromodulators and dermal fillers 149

Haruko Okada and David J. Rowe
17 Upper lid blepharoplasty 159
Ari S. Hoschander and Amie J. Kraus
18 Lower eyelid blepharoplasty 165
Urmen Desai, Andrew Rivera, and Richard Ellenbogen
19 Brow lift 173
Christopher J. Salgado, Tuan Tran, Steven Schuster, and Elizabeth Yim
20 Facelift: The extended SMAS technique 181
Ari S. Hoschander and James M. Stuzin
21 Rhinoplasty 187
Tara E. Brennan, Thomas J. Walker, and Dean M. Toriumi
22 Correction of prominent ear 201
Alejandra Garcia de Mitchell and H. Steve Byrd
23 Breast augmentation 207
Elliot M. Hirsch and John Y.S. Kim
24 Mastopexy 213
Leila Harhaus and Ming-Huei Cheng
25 Abdominoplasty, panniculectomy, and belt lipectomy 223
Ari S. Hoschander, Jun Tashiro, and Charles K. Herman
26 Brachioplasty 229
Anselm Wong, Samantha Arzillo, and Wrood Kassira
27 Medial thigh lift 233
Dennis J. Hurwitz
28 Liposuction 247
Alan Matarasso and Ryan M. Neinstein
 16
Non-surgical facial rejuvenation with
neuromodulators and dermal fillers

HARUKO OKADA AND DAVID J. ROWE

Introduction 149 Lateral periocular rhytids (crow’s-feet) 154

The aging face 150
Indications for injectable fillers 150
Indications for botulinum toxin injection for
facial rejuvenation 151
Pre-procedural details 151
Patient evaluation and facial analysis 151
Choice of product 152
Intraprocedural details 153
Transverse forehead lines 153
Glabellar lines 153
Nasojugal fold (tear trough) 154
Malar augmentation/nasolabial
fold correction 155
Depressor anguli oris 156
Marionette lines (prejowl sulcus) 156
Platysmal banding 156
Lip augmentation 156
CPT coding 157
Acknowledgment 157
References 157

Table 16.1  Special equipment

Alcohol wipes
Ice cube wrapped in 4 × 4 gauze
Injectable filler or botulinum toxin, in tuberculin syringe with 27- to 30-gauge needle or blunt needle
(DermaSculpt® Microcannula, Cosmofrance, Miami, FL)
Optional
Topical anesthetic (EMLA cream, LMX lidocaine 4% cream)
Hyaluronidase for HA fillers
Nitro paste

INTRODUCTION A injections followed by 1,662,480 hyaluronic acid

(HA) filler injections.1
Nonsurgical facial rejuvenation procedures are The first injectable filler approved by the Food
highly sought as more patients demand less-­ and Drug Administration (FDA) was bovine colla-
invasive, yet effective, procedures to mitigate gen (Zyderm®/Zyplast®, Inamed Aesthetics, Santa
signs of facial aging with minimal downtime. Barbara, CA),2 made available in 1981. Although
Nonsurgical procedures accounted for 82% of cos- this was a great leap forward from the preceding
metic procedures performed in the United States era of liquid silicone injections, bovine collagen
in 2011, with 4,030,318 botulinum toxin type could potentially cause severe allergic reactions,

149
150  Non-surgical facial rejuvenation with neuromodulators and dermal fillers

which required pre-treatment skin testing. Today,

collagen use has been largely replaced with HA
fillers, which have the benefit of causing far fewer
allergic reactions (0.6–0.8%)3 as they are olysac-
charides and not proteins. HA fillers also allow
correction of mistakes using hyaluronidase.4 There
is some evidence that HA fillers can stimulate de
novo synthesis of dermal collagen.5 Several HA
fillers are FDA approved: Restylane® (Medicis,
Scottsdale, AZ); Perlane® (Medicis); Juvederm®
(Allergan, Irvine, CA); Captique® (Allergan);
and Hylaform® (Allergan). Several other non-HA
fillers have gained FDA approval. These ­ fi llers
include calcium hydroxylapatite (Radiesse,®
Bioform Medical, San Mateo, CA); poly-L-lactic
acid (Sculptra®, ­Sanofi-Aventis, Bridgewater, NJ);
and polymethylmethacrylate or ArteFill® (Suneva
Medical, San Diego, CA).
With the explosive increase in filler-type
choices in the last decade, with and without pre-
mixed lidocaine,6 the aesthetic surgeon must
be well versed in the chemical and physiologic
­differences of each and the difference in injection
depths of the fillers.
Figure 16.1  Aging face: Gravitational descent,
skeletal change, soft tissue atrophy, photodam-
THE AGING FACE age, and muscular contraction all contribute to
the aging face.
The youthful face has smooth contours, few
­wrinkles at rest as well as animation, and appropri-
ate soft tissue fullness. With age, the skin accumu- In addition to the visible changes in the skin,
lates solar damage and shows uneven pigmentation there is marked thinning of subcutaneous ­tissues.
and loss in dermal thickness and elasticity. Rhytids The face has anatomically defined compart-
ultimately form due to a combination of these ments of fatty tissues8 that may not all descend or
skin changes, gravitational descent of soft tissues, thin  simultaneously. With this knowledge, there
and repeated muscular contractions (Figure 16.1). has been a paradigm shift in treating the aging
Transverse forehead lines appear with repeated face. No  longer are individual wrinkles treated
brow lifting by the frontalis muscle, worsened in to achieve a smooth and line-free face, but the
patients with eyelid ptosis, which leads to forehead combination use of neuromodulators and fillers
muscle compensation.7 Vertical lines form in the tackles both the soft tissue volume loss and lines
glabella with repeated ­contraction of the ­corrugator caused by muscle contraction.9 Table 16.1 indicates
supercilii, and crow’s-feet (lateral orbital rhytids) ­equipment needed for treatment.
appear lateral to the eyes from the concentric
movement of the orbicularis oculi. Further cau- INDICATIONS FOR INJECTABLE
dally, malar fat pads descend with gravity, starting FILLERS
a constellation of changes, including the appear-
ance of deepened nasolabial folds as well as jowling ●● Pronounced nasolabial fold
and resultant prejowl sulcus formation. Perioral ●● Marionette lines
rhytids form due to a multitude of concomitant ●● Perioral lines
factors. Loss of lip volume combined with contin- ●● Lip augmentation
ued orbicularis oris motion lead to a stellate-type ●● Jowl lines
pattern of vertical rhytids around the mouth. ●● Glabellar lines
 Pre-procedural details  151

●● Tear trough deformity Table 16.2  Lemperle wrinkle assessment scale

●● Facial lipoatrophy 0 No wrinkle
1 Just perceptible wrinkle
INDICATIONS FOR BOTULINUM 2 Shallow wrinkles
TOXIN INJECTION FOR FACIAL 3 Moderately deep wrinkle
REJUVENATION 4 Deep wrinkle, well-defined edges
●● Glabellar lines (FDA approved for Botox® 5 Very deep wrinkle, redundant fold
Cosmetic [Allergan]; Dysport® [Medicis,
Scottsdale, AZ]; and Xeomin® [Merz Pharma,
Frankfurt, Germany] at time of writing;
­off-label use for other indications)
●● Horizontal forehead lines
●● Crow’s-feet
●● Platysmal bands
●● Depressor anguli oris (DAO)

PRE-PROCEDURAL DETAILS
Patient evaluation and facial analysis
As with surgical rejuvenation, the patient’s goals
must be realistic and congruent with our treatment
plan. To achieve a successful outcome, the patient
must understand the limitations of non-surgical
facial rejuvenation. Fillers can augment soft tis-
sue volume, but the skin envelope excess cannot
always be addressed with non-surgical procedures
alone. Patients with unrealistic expectations must
be screened out prior to treatment, and we are obli-
gated to point out what is not correctable without
surgical intervention.
Assessment begins with a focused history and Figure 16.2  Facial thirds: The face is divided into
physical examination. Age is an important fac- equal partitions with divisions at the eyebrows
tor in the evaluation, as increased age may lead to and subnasale.
decreased immunogenicity and less inflammatory
risk; however, thinner skin can be less forgiving to photographs are strongly encouraged for self-­
an uneven injection of filler.10 A careful medication critique and improvement of technique.
history is obtained, and avoidance of nonsteroidal In evaluating the patient, the face is scrutinized
anti-inflammatory drugs (NSAIDs), blood thin- in an organized and systematic manner. A  well-
ners such as warfarin, and herbals such as gingko proportioned face has three zones of nearly equal
biloba for 36 hours and ginger for 2–3 weeks11 height: the upper third from the hairline to gla-
prior to injection is highly encouraged. Patients all bella, the middle third from the brow to the base of
undergo a standardized set of photographs prior to the nose, and the lower third from the base of the
any injection. nose to the chin point (Figure 16.2).
For charting purposes, it may be helpful to use a The top third of the face begins at the hair-
classification of facial wrinkles. The Lemperle scale line and extends inferiorly to above the brow.
(Table 16.2) of wrinkle severity is a validated scale12 Abnormalities such as a high-positioned hairline
from grades 0 to 5, with 0 being no perceptible lines are noted. Transverse forehead lines are assessed
to 5 being a deep wrinkle with a redundant over- with the patient in repose as well as with active
hanging soft tissue fold.13 Pre- and post-treatment brow elevation. Vertical glabellar lines may be
152  Non-surgical facial rejuvenation with neuromodulators and dermal fillers

marked prior to injection. To optimize results, the Juvederm, FDA approved in 2006, originally had
visible outline of the corrugator supercilii when an HA concentration of 24 mg/mL and a higher
frowning is noted. Laterally, temporal soft tissue percentage of cross-linking but is now available in
loss is assessed. a line of products with variable concentrations of
The middle third of the face extends from the HA, ranging from 18 to 30 mg/mL. Products with
brow to the base of the nose. Here, the focus is the a smaller ­particle size are more forgiving and allow
periorbital area. Periocular rhytids (crow’s-feet) for smoother injection. Products with a larger
are noted laterally. Transverse lines immediately ­particle size, such as Perlane and Juvederm Ultra,
cephelad to the nasion are a result of an overac- are marketed for a deeper dermis and subdermis
tive procerus muscle. Tear trough deformities are injection plane for moderate to severe wrinkles.
notoriously difficult to treat as these may be due Non-HA fillers can provide a much longer-­
to infraorbital fat herniation, and are likely not lasting effect but may potentially have longer-­
muscular in etiology. Furthermore, the infraor- lasting side effects in the hands of an inexperienced
bital region has thin, unforgiving skin and is prone clinician. Radiesse is a mineral scaffold of 30%
to bruising and surface irregularities from filler calcium hydroxylapatite spheres, ranging from
injection if injected superficially. 25–45 μm, approved for wrinkles as well as HIV
For the lower third of the face, the nasolabial facial lipoatrophy.18 The scaffold allows for tissue
fold and its infraoral continuation, the prejowl ingrowth, and the spheres are eventually encapsu-
sulcus (marionette lines), are pointed out to the lated by collagen fibers, leading to longer-lasting
patient. These lines form with the descent of sub- results than HA fillers. One study demonstrated
cutaneous tissues in the setting of thinning skin. an increased incidence of nodules when injected
Loss of projection and fullness of the lips, vertical in the lip and recommended against its use there.19
lines on the upper lip, and soft tissue loss on the Another study showed a lip nodule formation
lateral edges of the mental crease are noted. rate of 5.9% of 349 lip injections with Radiesse.
However, it was noted that the incidence declined
Choice of product to less than 2% for the last 100 injections, implying
the complication rate is dependent on clinician
The choice of fillers available on the market can experience.20
be overwhelming. Due to aggressive marketing of Poly-L-lactic acid is a biodegradable polymer,
each product in beauty magazines, on television, available in microspheres as Sculptra (Sanofi-
and online, patients may arrive with a choice of Aventis). It also stimulates collagen deposition
filler in mind. As the surgeon, it is paramount to gradually through a mild inflammatory response,
be well versed in the differences of each product. and clinical response is seen over time. Meticulous
It is beyond the scope of this chapter to discuss the injection with a fanning technique in the subder-
benefits of each product, but a brief description of mal plane is required to optimize results.21 It can
the general categories is discussed here. be used for HIV lipodystrophy and is injected
Hyaluronic acid (HA) is a naturally occurring in the subcutaneous plane. In our experience,
glycosaminoglycan ubiquitous in mammalian patients often need multiple injections spaced
extracellular matrix and is especially abundant in 2 months apart, with visible results expected in
loose connective tissue.14 It can bind 1000 times 4–6 months.
its volume in water, making it a relatively ideal Botulinum toxin type A is a neurotoxin secreted
soft tissue filler.15 In its natural form, the half-life by Clostridium botulinum. All type A toxins have
is 24 hours.16 Commercially available HA fillers the same mechanism of action: they cleave the pro-
have stabilized cross-linking, allowing for an tein SNAP-25, thus aborting the exocytosis of pre-
increased life span when compared to the natural synaptic vesicles containing acetylcholine. Because
product. the toxin works at the presynaptic neuromuscu-
HA products differ in chemistry by particle lar end plate, the toxin is injected into the muscle
size, HA concentration, and degree of cross-­ itself. At the time of publication, there are cur-
linking. Restylane was the first FDA-approved HA rently three brands of FDA-approved botulinum
filler; it has an HA concentration of 20 mg/mL, toxin type A available. Botox Cosmetic (onabotu-
gel particle size of 400 μm, and 1% cross-linking.17 linumtoxinA), Dysport (abobotulinumtoxinA),

and Xeomin (incobotulinumtoxinA). Although all
three are FDA approved for cosmetic use for gla-
bellar rhytides, other facial injections for cosmetic
use are currently off-label.
INTRAPROCEDURAL DETAILS
The patient is seated upright in a comfortable
examination chair. Anesthesia is paramount,
as a painful and anxious experience can deter
patients from repetitive treatments. Our method
of a­ nesthesia will differ slightly for each location.
We prefer to locally anesthetize areas of injection
by applying an ice cube wrapped in 4 × 4 gauze to
the area while carefully monitoring the comfort
of the patient. This is low cost as well as effective.
In our experience, patients tolerate the injections
that follow well after cooling, but topical anesthet-
ics such as EMLA (lidocaine/prilocaine) and LMX
creams can be used at the physician’s discretion.
Our personal compounded mixture for injections
is a benzocaine/lidocaine/tetracaine (20%/6%/4%,
respectively) mixture applied with occlusive
­dressing for 30 minutes.
Extremely sensitive areas such as the lips
can benefit from additional topical anesthetics.
Intraoral lidocaine ointment (5%) may be used
for the lips as well prior to mental and infraorbital
nerve blocks. Directions for use vary by manufac-
turer of the filler, but their directions often recom-
mend topical or injectable local anesthetic prior to
use. However, when using fillers with pre-mixed
lidocaine, additional anesthetic use is optional. The
recommended technique for pre-mixed formulas is
injecting a small amount of the filler and waiting
a full 3 seconds before injection of the remainder.
Currently, Radiesse and Sculptra are not available
in pre-mixed formulations but can be reconsti-
tuted at a ratio of 1.3 cc of Radiesse with 0.2 cc of
2% lidocaine HCl.22 A single vial of Sculptra can be
reconstituted with 2 mL sterile water for injection
and an additional 1 mL of 2% lidocaine HCl if a
pre-mixed anesthetic formula is preferred.23
Transverse forehead lines
This area is best treated with botulinum toxin, but
this can produce unnatural-looking results if the
clinician is not judicious. Assessment of the fore-
head and pre-existing brow ptosis needs to be car-
ried out. Deep transverse rhytids are a potential
Intraprocedural details  153
harbinger of brow ptosis, indicating ongoing acti-
vation of the frontalis to elevate the brow. A patient
who has brow ptosis prior to neuromodulator injec-
tion is at a significantly increased risk for worsen-
ing the ptosis with injection. It must be explained
to the patient that the goal is to slightly weaken,
not paralyze, forehead motion.
The number of injections depends on the num-
ber of lines to be treated. In our practice, approxi-
mately 10 total units of Botox are used for the
frontalis; however, this may range from 5 to 15
depending on severity. Dysport injections range
from approximately 30 to 60 units. The neuromod-
ulator is injected perpendicular to the skin directly
into the frontalis muscle at the level of the wrin-
kles bilaterally, avoiding the midline. Note  that
the skin tends to be relatively glaborous in the
forehead; thus injection to the level of the frontalis
necessitates deeper needle penetration to directly
inject to the level of the frontalis.
Glabellar lines
This area is also treated primarily with botulinum
toxin. If deep vertical glabellar rhytids still exist
after several rounds of botulinum toxin injection,
fillers may be employed. Often, though, the line
has decreased significantly and the patient will no
longer desire wrinkle correction through fillers in
this location.
We start with having the patient frown. Most
patients will exhibit a demonstrable lump, either
visible or palpable, of the corrugator supercilii
muscle from the medial brow, extending superi-
olaterally. The muscle dimensions are much larger
than previously described in anatomic draw-
ings. The corrugator begins 2.9 mm lateral to the
nasion and has an average width of 11 mm.24 We
use 25 units for this area, 12.5 units for each side,
using a 25-gauge 1¼-inch needle. In patients with
overtly  large corrugators, up to 35 total units of
Botox (50–80 units of Dysport) may be needed.
The injection is done with the clinician standing
to the patient’s side, gently supporting the superior
orbital margin with the index finger of the contra-
lateral hand. We inject laterally to inferiomedially,
guiding the needle deeper as we approach the mid-
line as the corrugator muscle fibers originate deep
above the nose and transition superficially as they
fan out into the superiolateral dermal insertion.
The product is deposited via retrograde injection.
154  Non-surgical facial rejuvenation with neuromodulators and dermal fillers
In patients who also have a vertical line just above
the nasion from a hyperactive procerus muscle, we
save 5 units for this (using 10 units for each side
of the corrugator and 5 units for the procerus,
totaling 25 units). A single injection point is made
in the transverse line at the nasion, and 5 units
is injected while fanning the needle from side to
side. Conversely, if the standard needle does reach
to the midline, this secondary injection site may
be avoided, and the product may thus be injected
from a lateral position. It is important to never
massage in these periorbital injections as this can
lead to eyelid ptosis from affecting the levator pal-
pebrae superioris (Figure 16.3).
Alternatively, the standard injection described
for botulinum toxin injection in the glabella
may be employed. This technique employs five
to seven discrete injections perpendicular to
the procerus and corrugators. Again, palpation
(a)
(b)
Figure 16.3  Botox to the glabella: authors’
technique. (a) The trajectory of the corrugator
is defined by the surface anatomy as well as by
repeating the patient’s mimetic motion. (b) The
neuromodulator is then injected in a retrograde
fashion.
and visualization are key for optimal ­placement
of the injection  sites. Note that the medial
corrugator injections will be deeper than the
­
­lateral i­njections given the corrugator anatomy
(see above).
Lateral periocular rhytids
(crow’s-feet)
The goal for this area is to paralyze the orbital
portion of the orbicularis oculi contributing to
crow’s-foot formation. We use no greater than
15  units of botulinum toxin per side, depositing
individually 1–3 units per crow’s-feet wrinkle with
a tuberculin syringe. On average, this is done on
two to five sites. The muscle is rather superficial,
and the correct depth of injection is a subcutane-
ous wheal (Figure 16.4). To protect the orbit and to
avoid injecting the medial palpebral part, a finger
is placed just medial to the lateral orbital rim while
injecting. Care is taken to avoid injection medial
to the bony orbit and above the inferior margin of
the zygoma. Although rare, injection in this region
may lead to ectropion.25
Nasojugal fold (tear trough)
The tear trough deformity is exclusively treated
with HAs in our clinic, as the skin and subcuta-
neous tissues are unforgiving; even a small lump
will be visible to the patient. If malar augmenta-
tion is desired, it is performed first, as there is
a possibility that the traction of the skin in the
malar region caused by the volume augmenta-
tion will aid the correction of the fold. If the tear
Figure 16.4  Crow’s-feet wheal. The lateral orbital
rhytids are injected in a subcutaneous plane as
the orbicularis is quite superficial.

trough is not corrected by this technique or malar
augmentation is not desired, the tear trough can
be treated directly.
Anesthesia via an ice cube is the primary modal-
ity used. Injection to the level of the preperiosteal
region is performed, and light massage is employed.
Minor incremental injections of 0.01 to 0.03 cc are
performed and visually assessed after each injec-
tion. Volume correction continues until the trough
decreases or disappears, depending on the desired
result and the amount of deformity noted.
Malar augmentation/nasolabial
fold correction
In the malar and nasolabial region, HA, calcium
hydroxyapatite, and poly-L-lactic acid may be used.
After photography and facial analysis, the patient’s
preferences are discussed. The option of separate
or combined malar volume increase/augmentation
and nasolabial fold injection is reviewed with the
patient. In our experience, most patients arrive
with the notion that the nasolabial fold is treated
most effectively with direct injection techniques.
If  the patient is an appropriate candidate, malar
augmentation may replace the loss of volume in
this area. A secondary but equally important effect
of malar augmentation is reduction of the nasola-
bial crease. In most instances, malar augmentation
decreases but may not eliminate the need for naso-
labial fold injection.
For malar injection, the two primary products
we use are HA and calcium hydroxyapatite. These
products may be placed within the substance of
the malar fat pads or conversely in the preperios-
teal tissue. The malar bone is palpated, and com-
mercial eyeliner pencil is used to outline the region
to be augmented as this comes off much more
easily than surgical marker. In a gridlike fashion,
0.1–0.2 cc filler is deposited in the deep subcutane-
ous, preperiosteal plane, 3–5 mm apart. After each
deposit, the filler is carefully and gently massaged
into the tissue. Nodule formation can be mini-
mized if the injections are deep. The end point for
injection is when there is satisfactory resolution
of the nasolabial fold (as malar augmentation can
gently balloon out the midfacial skin, decreasing
the nasolabial fold) or when adequate projection
is reached, whichever is achieved first. Therefore,
the total volume of injection can be highly variable
for this area. Prior to injection, the total volume of
Intraprocedural details  155
product that may be injected is discussed with the
patient. It is also discussed that one syringe may
not be enough to achieve the desired results. After
approximately one syringe of product, the patient
is handed a mirror, and the effects are noted by
both patient and doctor. If more volume is needed
to achieve optimal results, the patient and doctor
may decide for more product at that time. Poly-L-
lactic acid may also be employed in malar augmen-
tation; however, the product is primarily placed in
the subdermal plane with a fanning technique.
The nasolabial fold area may be treated with
HA, calcium hydroxyapatite, or poly-L-lactic acid.
Several techniques may be utilized here to achieve
optimal results. A subdermal fanning technique is
used, starting at the oral commissure and directed
toward the cephalic extent of the nasolabial fold at
the ala. Product is placed in a retrograde injection
fashion. Separately or in conjunction with the fan-
ning technique, the fold may be corrected using
a perpendicular radial-type injection that starts
lateral to the nasolabial fold and ends medial to
it, theoretically providing a scaffold-type archi-
tecture (Figure 16.5). For downturning of the oral
commissure, 0.1–0.2 cc of filler is injected into the
depressions bilaterally. We find that one syringe
of filler usually suffices to correct the fold, and
patients who need further correction benefit from
malar augmentation, as previously mentioned.
Figure 16.5  Injection technique for malar/­
nasolabial fold. If the patient has malar descent/
atrophy, injection is first in an aliquot fashion
at the malar bone in a supraperiosteal plane
(blue circles on right side of face). If adequate
­nasolabial elevation is not achieved, standard
injection in the nasolabial fold is then performed
using a combination of serial threading (green
arrows) and crosshatching (blue arrows).
156  Non-surgical facial rejuvenation with neuromodulators and dermal fillers

Depressor anguli oris

The depressor anguli oris muscle originates from
the oblique line of the mandible and inserts into the
inferior aspect of the mouth and oral ­commissures.
Although this muscle depresses the corners  of  the
mouth during a frown, it is counteracted by the zygo-
maticus major and minor muscles used in a smile.
Botulinum toxin injection to this muscle can change
facial expression into a more pleasing one, similar to
treating the glabellar muscle group used in the frown.
2–5 units of Botox or 6–15 units of Dysport are used
per side, depending on the size of the m ­ uscle.26
Because many muscles insert into the modiolus, it
is important to isolate just the depressor anguli oris
and limit the injection to its origin at the mandible.

Marionette lines (prejowl sulcus)

Marionette lines form at the junction of the oral
commissure and the caudal extent of the malar
region. The main causal agent is gravity’s effect on
the malar region. Caudal descent of the malar tis-
sue and laxity of the skin lead to jowling and for-
mation of the vertical step-off known as the prejowl
sulcus. This is a technically challenging region as
overfill here may lead to a cosmetically unaccept-
able appearance of fullness, whereas undercor-
rection will likely lead to continued visualization
of the prejowl sulcus. Prior to any injection, the
etiology of the prejowl sulcus is explained to the
patient while the patient is looking in a m ­ irror.
Cephalolateral traction on the cheek skin is an
effective measure not only to define the results of
a rhytidectomy in this region but also to demon-
strate that volume in this region may mask the
issue and thus provide a cosmetically acceptable
result but will not correct the issue of jowling.
Hyaluronic acid products as well as calcium
hydroxyapatite are used in this region. Following
anesthesia (if needed), several techniques may be
employed. Correction of the oral commissure (see
above) often is performed first; this can be consid-
ered the cephalic extent of the marionette lines in
most individuals. A combination of linear paral-
lel subdermal injection for volume correction as
well as serial injections perpendicular to the pre-
jowl sulcus are frequently used (Figure 16.6). The
serial injections may replace volume here as well as
provide a soft scaffolding for cephalolateral trans-
lation of the caudal cheek. The caudal border of
Figure 16.6  Injection technique for m ­ arionette
lines. If the oral commissure is affected,
a 0.1–0.2 cc aliquot of product is placed deep in
this region (circle) and a small thread of product
is placed along the lip border. The marionette
lines themselves are then treated first by serial
and linear threading (green arrows). If the amount
of tissue laterally is too great, crosshatching
(blue arrows) is also utilized to provide better
transition and scaffolding to the area.
the prejowl sulcus and jowl may be corrected with
­volume as well, providing a more uniform line
along the border of the mandible.
Platysmal banding
Platysmal banding may be corrected with the use
of neuromodulators. On examination, the patient
is asked to activate the platysma. The banding is
then marked with an eyeliner as a reference for
injection. Injection points may range from 2 to
approximately 10 as necessary. Each injection site
is injected with 2–4 units of Botox, up to 12 units
per band, with up to a total of 20–40 units.
Lip augmentation
Often in our clinic, patients will not request lip
augmentation but will desire correction of vertical
perioral rhytids. On further questioning, most of
these patients have lost significant volume in their
lips. Lipstick may be more difficult to apply because

vermillion is less descript. They are hesitant for lip
augmentation because they have seen the resultant
“duck lip” look in many tabloid photographs. The
first goal in treatment of the lips is to assure the
patient that the result will be natural. Some will
desire larger-volume augmentation, but we always
start an initial injection with a conservative volume.
In our practice, only HA products are used in
the lips. Calcium hydroxyapatite is felt to have
an unacceptable feel as well as the possibility for
nodule formation. Two modalities of anesthesia
are employed in our clinic. First, the patient may
receive an infraorbital nerve block as well as men-
tal nerve block. These are relatively well tolerated;
however, they leave the patient numb for several
hours, resulting in drooling, slurred speech, and
asymmetric oral mimetic movement. The second
technique is the use of cooling combined with HA
plus lidocaine. This also is well tolerated and leaves
the patient with fewer of the sequelae mentioned.
Following the oral commissure correction (see
above), the substance of the lip is injected with a lon-
gitudinal threading technique with retrograde injec-
tion. This is the primary modality used in our clinic
because volume correction is the primary issue in
most individuals. A separate linear injection along
the vermillion may be employed, but often after vol-
ume augmentation the vermillion border needs little
to no augmentation. The injection site is posterior to
the wet-dry junction of the lip, and the needle will
pass parallel to this line. The needle is then rein-
jected at the site of furthest travel until the midline
is encountered. Following the terminal midline
injection, the remainder of the lip injection is begun
from the contralateral oral commissure. During the
entire threading technique, approximately 0.05  cc
is injected retrograde with every injection. The cen-
tral lip receives slightly more, approximately 0.07 to
0.1 cc total, depending on the atrophy of the tissue.
The upper lip is performed first, and the patient is
allowed to visualize the final result of the upper lip
compared to the “native” lower lip. This gives the
patient the ability to see the efficacy of the product
during the process and usually relaxes the patient
because the upper lip will look fuller but natural
when compared to the lower lip.
Approximately 0.2 cc of a syringe is usually
stored for up to 2 weeks in a sterile fashion. This
allows the doctor and patient to correct any asym-
metry of the lip (or other injection site) without
incurring more cost. It is explained to the patient
References 157
prior to the initial procedure that if no asymme-
try or defect is encountered or the patient does not
make it back to the clinic during this time that the
product will be discarded.
CPT CODING
64612 Chemodenervation of muscle(s); muscle(s)
innervated by facial nerve
ACKNOWLEDGMENT
We wish to thank Stephanie Levandusky for her
photographic analysis and J. Jordi Rowe, MD, for
the artwork.
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­injectable facial fillers. Facial Plast Surg.
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5. Wang F, Garza LA, Kang S, et al.
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10. Kinney BM, Rowe DJ, Stepnick D. Non-
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 17
Upper lid blepharoplasty

ARI S. HOSCHANDER AND AMIE J. KRAUS

Introduction 159 Notes 163

Preoperative markings 160 CPT coding 163
Intraoperative details 161 Suggested readings 163
Postoperative care 162 Acknowledgment 163

INDICATIONS

The indications for upper lid blepharoplasty are of both aesthetic and functional importance. Patients
present with aesthetic concerns corresponding to findings on physical exam. Common symptomology
includes periorbital wrinkles, redundant upper eyelid skin, low supratarsal fold, upper lateral periorbital
rhytids, or peripheral visual field deficits (Figure 17.1).
Note: Certain medical conditions increase the risk of complications and should be evaluated prior to
upper lid blepharoplasty. Included in these conditions are

1. Autoimmune disorders (collagen vascular 3. Eyelid inflammatory disorders

diseases) 4. Benign essential blepharospasm
2. Grave disease 5. Dry eye syndrome

Table 17.1  Special equipment

Blepharoplasty instrument tray Betadine sterile skin prep
#15 blade, SuperSharp Cotton swabs
Ophthalmic lubricant (corneal protectors may be used) Needle-tip cautery
Calipers (non-sterile for preoperative marking and sterile Thin-tip marking pen
for intraoperative measurements)

INTRODUCTION one can have excellent aesthetic and functional

The goals of upper lid blepharoplasty are to restore
upper orbital shape and a defined upper lid crease.
The procedure is intricate and challenging. With
proper preoperative assessment and planning,
outcomes.
Upper lid blepharoplasty requires ­careful pre-
operative assessment. A detailed history and physi-
cal that focuses on the orbit, brow, lid, and midface
must be obtained. The patient should be sent for
159
160  Upper lid blepharoplasty
a formal ophthalmologic exam for evaluation and
clearance.
Patients at risk for dry eye should be evaluated
in the office as part of the preoperative assessment
using the Schirmer test; this will help guide peri-
operative planning and postoperative care. Patients
should also be assessed for ptosis, asymmetry,
height of supratarsal fold, lagophthalmos, brow
position, as well as lacrimal gland prolapse. This
chapter focuses purely on the aesthetic procedure,
but it should be noted that a functional procedure
may be necessary based on the findings in the pre-
operative evaluation. Table 17.1 indicates special
equipment needed.
Figure 17.1  The aged eye. Note the redundant
upper eyelid skin, folds, and periorbital wrinkles.
(a)  
Figure 17.2  Preoperative markings. (a) Distance between the lower border of the eyebrow and the
upper eyelid marking at the level of the lateral canthus should never be less than 10 mm in length and
usually between 10 and 15 mm for skin preservation. (b) Distance between lash line and upper eyelid
crease at the level of the mid-pupillary line; in women, this distance is usually 10 mm and in men
approximately 8 mm.
PREOPERATIVE MARKINGS
To obtain precise preoperative markings, the cur-
rent preferred practice is to have the patient sitting
in the preoperative area. The surgeon may obtain
markings with the aid of loupe magnification and
with caliper measurements to confirm symmetry
of markings bilaterally (Figure 17.2).
1. Mark the upper eyelid crease at the level of
the mid-pupillary line.
a. In women: ~10 mm superior to the lash
margin
b. In men: ~8 mm superior to the lash margin
2. This marking should be tapered caudally at
the nasal and lateral eyelid margins so that it
­follows the curve of the upper eyelid crease.
3. Do not extend the nasal aspect too far
­medially; this will avoid webbing or epicanthal
folds above the medial canthus.
a. The amount of tissue to be excised nasally
should be conservative because over-­
resection of skin and muscle can lead to poor
aesthetic outcomes and result in lagophthal-
mos and corneal exposure and dryness.
4. The lateral marking should be ~5–6 mm above
the lash line. We mark the lateral extent of our
incision at a point where the redundancy ends
within a periorbital rhytid.
5. To determine the superior margin of the
­excision, pinch and identify the quantity of
excess skin and muscle.
(b)
 Intraoperative details  161

Figure 17.3  Skin incision and complete excision of skin.

6. At minimum, 10 mm (some authors say 15 mm)

of skin should be preserved between the lower
border of the eyebrow and the upper eyelid
marking at the level of the lateral canthus.
7. To complete the superior mark, follow a gentle
curve that parallels the contour of the lower
marking and taper nasally to reduce the amount
of skin and muscle that is removed along the
nasal half of the incision. We sometimes angle
the last portion of the nasal aspect of the inci-
sion at a 45° angle upward (not shown).
8. Pay attention to the presence of eyebrow and
eyelid fold asymmetry, because if asymmetri-
cal brow positions are present preoperatively,
the upper eyelid markings should closely Figure 17.4  Incision of strip of orbicularis oculi
muscle to expose the orbital septum using
approximate one another, but a concurrent
needle-tip cautery.
procedure should be planned to correct brow
position.
a. Symmetry can be achieved by r­ emoving 5. Using a #15 blade scalpel, make a skin i­ ncision
­different amounts of skin and muscle along preoperative markings o ­ utlined.
­during the operative procedure. Completely excise the skin within these
­markings (Figure 17.3).
INTRAOPERATIVE DETAILS 6. Use needle-tip cautery to incise the orbicularis
oculi muscle within the incision to expose
1. Prep the skin with Betadine® (Purdue the orbital septum and completely excise a
Products, Stamford, CT) and drape small strip of muscle. Cotton applicator sticks
accordingly. are used for gentle retraction; use needle-tip
2. Place eye lubricant and corneal protectors ­cautery to obtain hemostasis to cauterize
(protection of the globe varies for the awake ­vessels in the area (Figure 17.4).
patient). 7. Open the orbital septum with tenotomy
3. Infiltrate along preoperative skin markings ­scissors or a hemostat, enter the pre-­
and within the markings using a local anes- aponeurotic space, and expose the orbital fat.
thetic containing epinephrine. The septum should be opened along the upper
4. A 4-0 silk suture can be passed through the incision to avoid injury to the aponeurosis.
upper eyelid margin and secured to the drape The aponeurosis is located posterior to the
for fixation to allow for traction, although we orbicularis muscle at the lower incision in
do not routinely do this. the eyelid crease (Figure 17.5).
162  Upper lid blepharoplasty
Figure 17.5  Tenotomy scissors are used to open the orbital septum, then dissected with a clamp
to enter the pre-aponeurotic space; this exposes the orbital fat pads. Nasal fat pad excision using
­needle-tip cautery in a sculpting fashion. Attention is given to the interpad septum between
the ­central and nasal compartments.
8. In a conservative fashion, and if indicated,
remove fat from the nasal compartment. It is
important to preserve the interpad septum
between the central and nasal compartments.
9. Almost in a sculpting fashion, use the
­needle-tip cautery to carefully excise the fat
in this region. This method is preferred over
­clamping, resecting, or cauterizing fat because
it allows for greater precision and visualiza-
tion of the medial palpebral artery, therefore
avoiding uncontrolled bleeding.
a. Consider fat pad preservation to avoid cre-
ating a hollow, more aged-appearing orbit.
10. Excess skin and muscle are resected with
scissors.
11. Note the position of the lacrimal gland.
A ­prolapsing lacrimal gland needs to be
­repositioned within the lacrimal gland fossa.
This is accomplished using a 6-0 Vicryl®
(Ethicon, Somerville, NJ) suture at the level
of the lacrimal gland, suturing the levator
­aponeurosis to the arcus marginalis. Do not
resect the lacrimal gland, as it will result in
postoperative dry eye.
12. Throughout the procedure, it is of utmost
importance to maintain meticulous hemostasis.
13. Irrigate with normal saline solution.
14. The incision lateral to the canthus is closed
with interrupted 6-0 nylon sutures approxi-
mating the skin only.
15. The incision medial to the lateral canthus
is closed first with a few 6-0 nylon sutures,
incorporating skin and muscle to help restore
the supratarsal crease. The remainder of
the incision is closed with running 6-0 nylon
suture that will require postoperative removal.
16. Repeat on the contralateral side, paying
­careful attention to obtain symmetry.
1 7. Remove corneal protectors and rinse the eyes
with a balanced salt solution.
POSTOPERATIVE CARE
Patients generally tolerate the procedure well and
are discharged home the same day from the ambu-
latory surgery unit. Immediately postoperatively,
begin placing ice/cold packs to the peri-orbital
region for at least the first 48 hours following
­surgery. Encourage head elevation. These measures
are to aid in the reduction of postoperative edema.
Patients are often given ophthalmic a­ntibiotic
­ointment for application along the suture line and
on the globe to lessen ­evaporative tear loss. Patients
are strongly advised to rest and avoid strenuous
activity for the first 2 weeks. No makeup, lotions,
or face creams are to be applied to the face in the
periorbital region during the postoperative period.
Follow-up in 5 to 7 days for removal of sutures and
evaluation is standard practice.
It is important to be aware of the mechanisms
of complications in order to anticipate and prevent
them. The most frightening complication follow-
ing upper lid blepharoplasty is vision loss. It is
usually caused by either retro-orbital hemorrhage
or direct globe perforation. Initial management
requires surgical decompression accompanied by
the administration of mannitol or acetazolamide.
Another common complication following upper

lid blepharoplasty is diplopia. Usually temporary,
it is the result of postoperative edema. However,
diplopia can be permanent as a result from injury
to the oblique muscles.
NOTES
It is preferred to begin applying cold compress to
the periorbital region even prior to beginning the
operation for the contralateral eye.
CPT CODING
15822 Blepharoplasty, upper eyelid
15823 Blepharoplasty, upper eyelid; with excessive
skin weighting down lid
SUGGESTED READINGS
Burroughs JR, McLeish WM, Anderson RL.
Upper blepharoplasty combined with
­levator aponeurosis repair. In: Fagien S, ed.
Putterman’s Cosmetic Oculoplastic Surgery.
4th ed. Philadelphia, PA: Saunders;
2007:115–122.
Acknowledgment 163
Codner MA, Ford DT. Blepharoplasty. In: Thorne
CH, ed. Grabb and Smith’s Plastic
Surgery. 6th ed. Philadelphia, PA: Wolters
Kluwer/Lippincott, Williams & Wilkins;
2007:486–497.
Dewan MA, Meyer DR. Upper eyelid
­blepharoplasty. In: Black EH, Nesi FA,
Calvano CJ, Gladstone G, Levine MR,
eds. Smith and Nesi’s Ophthalmic Plastic
and Reconstructive Surgery. New York,
NY: Springer Science + Business Media;
2012:447–453.
Nahai F. Clinical decision making in a ­ esthetic
eyelid surgery. In: Nahai F, ed. The Art
of Aesthetic Surgery: Principles and
Techniques. St. Louis, MO: Quality Medical;
2005:651–678.
Potter JK, Clifford CP III, Janis JE. Blepharoplasty
and browlift. Sel Readings Plast Surg.
2005;10:1–35.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 18
Lower eyelid blepharoplasty

URMEN DESAI, ANDREW RIVERA, AND RICHARD ELLENBOGEN

Introduction 166 Intraoperative details 168

Transconjunctival approach to lower
blepharoplasty 166
Preoperative markings 166
Intraoperative details 166
Subciliary skin-muscle flap lower
blepharoplasty 168
Preoperative markings 168
Subciliary skin-only flap lower blepharoplasty 169
Preoperative markings 169
Intraoperative details 169
Postoperative care 170
CPT coding 171
Acknowledgment 171
Suggested readings 171

INDICATIONS

1. Lower eyelid blepharoplasty can be utilized a. Transconjunctival approach: Indicated for

to surgically manage patients with any of the
following indications:
a. Excess infraorbital fat
b. Pseudoherniation of fat
c. Redundant skin and muscle
d. Lower eyelid malposition
2. There are currently a number of techniques
and surgical approaches to correct
imperfections of the periorbital region,
particularly with regard to the lower eyelid.
These include the following:
patients with pseudoherniation of fat and
minimal or no excess skin
b. Subciliary approach with skin-muscle
flap: Indicated for patients with
pseudoherniation of fat, excess skin, and
redundant orbicularis oculi
c. Subciliary approach with skin-only
flap: Indicated for patients with both
pseudoherniation of fat and excess skin
only, with preservation of the orbicularis
oculi

Table 18.1  Special equipment

0.5% topical ophthalmic tetracaine
hydrochloride
1% lidocaine with 1:100,000 epinephrine
30-gauge needle
Lubricating ophthalmic ointment
Corneal shield
(Continued)

165
166  Lower eyelid blepharoplasty

Table 18.1 (Continued)  Special equipment

Mosquito hemostat
Needle-tip electrocautery
5-0 nylon suture
6-0 fast-absorbing gut suture
Desmarres retractor
Small blunt-tip dissection scissor
Cotton-tip applicators

INTRODUCTION
One of the first areas in the face to demonstrate
significant signs of aging is the periorbital region.
Surgical procedures to restore a youthful appear-
ance to the lower lid region date back over 2000
years, with various techniques used to reduce
redundant tissue and excess skin. To be considered
a candidate for surgery, a patient must undergo a
preoperative evaluation consisting of a ­thorough
review of all ocular and medical problems,
­particularly with regard to the following:

1. Prior periorbital surgery

2. Visual deficits
3. Glaucoma
4. Dry eye symptoms
5. Medical history (e.g., comorbidities such
as hypertension, diabetes, or t­ hyroid
­disease which can prevent adequate
wound healing)
6. Medications (e.g., anticoagulation, vitamin E,
ginkgo biloba)
7. Smoking
Knowledge of the medical history and ophthal-
mic conditions is crucial as the procedure could
potentially exacerbate or worsen such conditions.
A preoperative ophthalmology evaluation can help
identify some of these conditions. Table 18.1 indi-
cates special equipment needed for this procedure.
TRANSCONJUNCTIVAL APPROACH
TO LOWER BLEPHAROPLASTY
(FIGURES 18.1 AND 18.2)
Preoperative markings
1. A marking pen is used to make surgical
­markings 4 mm inferior to the lower border of
the tarsal plate to preserve the orbital septum.
Figure 18.1  Transconjunctival incision: Indicated
for patients with pseudoherniation of fat and
minimal or no excess skin.
2. The medial extent of the markings should be
in line with the inferior punctum.
3. The lateral extent of the markings should be
4–5 mm medial to the lateral canthus.
Intraoperative details
1. Two drops of 0.5% tetracaine hydrochloride
are instilled into each inferior fornix.
2. Corneal eye shields are placed bilaterally.
3. The lower lid conjunctiva is injected with
1 cc 1% lidocaine with 1:100,000 epinephrine
using a 30-gauge needle.
4. A needle-tip electrocautery is used to
make a transconjunctival incision as previ-
ously marked, keeping the orbital septum
intact.
 Transconjunctival approach to lower blepharoplasty  167

Figure 18.2  Transconjunctival removal of

­pseudoherniated fat while preserving lower lid Figure 18.3  A 5-0 nylon suture is placed through
skin and orbicularis oculi muscle. the conjunctiva closest to the fornix to retract the
posterior llamella over the cornea with a mos-
quito hemostat held on the patient’s head wrap
to hold the suture under tension (Frost retention
5. A 5-0 nylon suture is placed through the suture).
conjunctiva closest to the fornix to retract
the posterior llamella over the cornea
with a mosquito hemostat held on to the
patient’s head wrap to hold the suture
under tension (Frost retention suture)
(Figure 18.3).
6. Simultaneous eversion of the lower
­eyelid using a Desmarres retractor and
­gentle ­pressure on the globe will produce
a bulge of orbital fat which helps guide the
dissection.
7. Blunt dissection with the assistance of a
cotton-tip applicator is performed until
the medial, central, and lateral fat pads are
identified.
8. A fine forceps is used to carefully tease out
Figure 18.4  A fine forceps is used to carefully
the excess fat with care to remove only the tease out the excess fat so only the excess herni-
excess herniated fat to prevent a hollowed-out ated fat is removed to prevent a hollowed-out
appearance (Figure 18.4). appearance.
9. A mosquito hemostat is used to clamp the
fat pad at its stalk. The fat pad is then tran-
sected with a needle-tip electrocautery and right lower eyelids is performed for
(Figure 18.5). symmetry.
10. After resection of fat, the surgical field is 1 1. The volume of fat removed from each fat com-
­examined until meticulous ­hemostasis partment can then be compared between sides
is achieved, and a comparison of left (Figure 18.6).
168  Lower eyelid blepharoplasty
Figure 18.5  A mosquito hemostat is used
to clamp the fat pad at its stalk, and is then
­transected with needle-tip electrocautery.
Figure 18.6  The volume of fat removed from
each fat compartment can be compared
between sides.
12. Finally, fat repositioning may be performed
to fill in more inferior orbital hollowing by
redraping the fat over the arcus marginalis
and to fill nasojugal deficiencies after releasing
the orbitomalar ligament.
13. Additional facial fat grafting to the nasojugal
grove or tear trough can also be performed as
an adjunctive procedure.
14. The conjunctival incision can then be
­reapproximated with or without suture
closure.
15. Adjunctive procedures to treat excess skin can
now be performed, including chemical peel,
laser resurfacing, or skin-pinch excision.
Figure 18.7  Subciliary approach with
skin flap: Indicated for patients with both
­pseudoherniation of fat and excess skin with or
without redundant orbicularis oculi.
SUBCILIARY SKIN-MUSCLE FLAP
LOWER BLEPHAROPLASTY
(FIGURE 18.7)
Preoperative markings
1. A subciliary incision is marked out 2 mm
beneath the eyelid margin.
2. The medial extent of the marking lies 1 mm
lateral to the inferior punctum to avoid poten-
tial injury to the interior canaliculus.
3. The lateral extent of the marking lies
8–10 mm lateral to the lateral canthus,
curving infero-laterally and blending
into a natural periorbital rhytid.
Intraoperative details
1. Two drops of 0.5% tetracaine hydrochloride
are instilled into each inferior fornix.
2. Corneal eye shields are placed, bilaterally.
3. 1 cc of 1% lidocaine with 1:100,000 epinephrine
is injected along the surgical markings down to
the infraorbital rim.
4. A #15 blade is used to make a skin incision to
the lateral canthus. Lateral to this point, a skin-
and-muscle incision is made.

5. A small blunt-tip dissection scissor is used to
dissect in a submuscular plane from lateral to
medial.
6. A 5-0 nylon suture is then placed through the
gray line lateral to the limbus above the inci-
sion for counter-retraction and to protect the
globe (Frost retention suture).
7. Blunt dissection is then performed using a
combination of a cotton-tip applicator and a
small blunt-tip dissection scissor until a skin-
muscle flap is developed down to the level of
the infraorbital rim.
8. Simultaneous eversion of the lower eyelid with
a Desmarres retractor and gentle pressure on
the globe produces a bulge of orbital fat which
helps to guide the dissection.
9. Blunt dissection through the orbital septum is
performed with the assistance of a cotton-tip
applicator and the small blunt-tip dissection
scissors until the medial, central, and lateral
fat pads are identified and penetrated through
the orbital septum.
10. A fine forceps is used to carefully tease out
the excess fat with care to remove only the
excess herniated fat to prevent a hollowed-out
appearance.
11. A mosquito hemostat is used to clamp the fat
pads at their stalk. The fat pad is then transected
with a needle-tip electrocautery (Figure 18.8).
12. After resection of fat, the surgical field is
examined until meticulous hemostasis is
achieved, and a comparison of left and right
lower eyelids is performed for symmetry.
13. The volume of fat removed from each fat com-
partment can then be compared between sides
(Figure 18.6).
Figure 18.8  A mosquito hemostat can be used
to clamp the fat pads at their stalk, and the pads
can subsequently be transected with a needle-tip
electrocautery.
Subciliary skin-only flap lower blepharoplasty  169
14. Finally, fat repositioning may be performed
to fill in more inferior orbital hollowing by
redraping the fat over the arcus marginalis
and to fill nasojugal deficiencies after releasing
the orbitomalar ligament.
15. Additional facial fat grafting to the nasojugal
grove or tear trough can also be performed as
an adjunctive procedure.
16. A lateral canthoplasty, canthopexy, or tarsal
strip procedure can then be performed at this
point to restore eyelid position.
17. The inferior skin-muscle flap is then redraped
over the subciliary incision, and the redun-
dant skin-muscle overlap is marked and
conservatively resected.
18. 6-0 fast-absorbing gut suture is then used to
reapproximate the skin incision in a running
fashion.
SUBCILIARY SKIN-ONLY FLAP
LOWER BLEPHAROPLASTY
Preoperative markings
1. A subciliary incision is marked 2 mm beneath
the eyelid margin.
2. The medial extent of the marking lies 1 mm lat-
eral to the inferior punctum to avoid potential
injury to the interior canaliculus.
3. The lateral extent of the marking lies 8–10 mm
lateral to the lateral canthus, curving infero-­
laterally and blending into a natural periorbital
rhytid.
Intraoperative details
1. Two drops of 0.5% tetracaine hydrochloride
are instilled into each inferior fornix.
2. Corneal eye shields are placed bilaterally.
3. 1 cc of 1% lidocaine with 1:100,000 ­epinephrine
is injected along the surgical markings
down to the infraorbital rim using a 30-gauge
needle.
4. A #15 blade is used to make a skin-only incision.
5. A 5-0 nylon suture is then placed through the
gray line lateral to the limbus above the inci-
sion for counter-retraction and to protect the
globe (Frost retention suture).
6. Careful blunt dissection is then performed
using a combination of a cotton-tip applica-
tor and a small blunt-tip dissection scissors
170  Lower eyelid blepharoplasty
to develop a skin flap down to the level of the
infraorbital rim.
7. Simultaneous eversion of the lower e­ yelid with
a Desmarres retractor and gentle ­pressures on
the globe produces a bulge of orbital fat which
helps to guide the dissection.
8. Blunt dissection through the orbital s­ eptum
is performed with the assistance of a cotton-
tip applicator and a small blunt-tip d ­ issection
scissor until the medial, c­ entral, and lateral
fat pads are i­ dentified and penetrated through
the orbital septum.
9. A fine forceps is used to carefully tease out
the excess fat with care to remove only the
excess herniated fat to prevent a hollowed-out
appearance.
10. A mosquito hemostat is used to clamp the
fat pads at their stalk. The fat pad is then are
­transected with needle-tip electrocautery.
11. After resection of fat, the surgical field is
examined until meticulous hemostasis is
achieved, and a comparison of left and right
lower eyelids is performed for symmetry.
12. The volume of fat removed from each fat
­compartment can then be compared between
sides (Figure 18.7).
13. Finally, fat repositioning may be performed
to fill more inferior orbital hollowing by
KEY POINTS
1. Key indicators for surgery are as follows:
a. Choose the right patient for the operation
and the right operation for the patient.
b. Age-related changes to periorbital skin
and fat content are among the first to
occur in the face. Even minor cor-
rections of these entities can lead to
significant rejuvenation and restoration
of a more youthful appearance.
c. A thorough preoperative evaluation is
essential in determining the candidacy
and surgical approach that is ideal
for correcting periorbital aesthetic
imperfections.
d. Ophthalmic conditions need to be
evaluated by an ophthalmologist prior
to any operative intervention.
redraping the fat over the arcus marginalis
and to fill nasojugal deficiencies after releasing
the orbitomalar ligament.
14. Additional facial fat grafting to the nasojugal
grove or tear trough can also be performed as
an adjunctive procedure.
15. A lateral canthoplasty, canthopexy, or tarsal
strip procedure can then be performed at this
point to restore eyelid position.
16. The inferior skin flap is then redraped over
the subciliary incision, and the redundant skin
overlap is marked and conservatively resected.
17. A 6-0 fast-absorbing gut suture is then used to
reapproximate the skin incision in a running
fashion.
Postoperative care
1. Head of bed at 45°.
2. Cold compresses to reduce immediate post­
operative edema for 24–48 hours.
3. Close observation for any indication of
retrobulbar hematoma for at least 1–2 hours
postoperatively and discharge only after a thor-
ough visual examination is performed.
4. Ocular lubrication with artificial tears and
nighttime lubrication with ophthalmic bacitra-
cin ointment.
e. A conservative skin-muscle or ­skin-only
flap resection is recommended to
­prevent complications.
f. Meticulous hemostasis is crucial for
reducing the chance of developing a
postoperative retrobulbar hematoma.
2. Complications of blepharoplasty to be
­cognizant of include the following:
a. Retrobulbar hematoma/visual loss:
Vascular injury during surgery with
retraction of the vessel into the retro-
bulbar space can lead to this potentially
catastrophic complication. This would
present with proptosis and chemosis
that becomes progressively worse. Loss
of visual acuity can be indicative of
optic nerve ischemia. This complication

typically occurs within the first
4 to 6 hours postoperatively and requires
prompt opening of incisions, saline
compresses, intravenous treatment
with mannitol, diamox, and decadron,
and control of hypertension and any
coagulopathies.
b. Ectropion: Postoperative scleral show
can be due to edema or weakness of
the orbicularis oris muscle and resolves
with edema resolution and muscle
reinnervation.
c. Corneal injury: Lubrication is the best
measure to prevent this.
5. Strict instructions to limit physical activity for
2 weeks postoperatively.
6. Close monitoring on follow-up examination for
any signs of development of ectropion, scleral
show, or any changes in lid contour or position.
CPT CODING
15820 Lower eyelid blepharoplasty
15821 Lower eyelid blepharoplasty, with extensive
herniation of fat pad
67909 Reduction of overcorrection of ptosis
67911 Correction of lid retraction
67914 Repair of ectropion; suture
67915 Repair of ectropion; thermocauterization
67916 Repair of ectropion; excision tarsal wedge
67917 Repair of ectropion; extensive (e.g., tarsal
strip operations)
67921 Repair of entropion; suture
67922 Repair of entropion; thermocauterization
67923 Repair of entropion; excision tarsal wedge
67924 Repair of entropion; extensive (e.g., tarsal
strip or capsulopalpebral fascia repair)
67950 Canthoplasty (reconstruction of canthus)
67999 Unlisted procedure, eyelids
Suggested readings  171
d. Dry eyes: Injury to the lacrimal gland,
excessive skin resection, and postopera-
tive edema can lead to this.
e. Epiphora: This is common postopera-
tively during the first 48 hours due to
edema or a temporary decrease in muscle
tone.
f. Extraocular muscle injury: The inferior
oblique muscle is vulnerable to injury
during dissection of fat compartments
in the lower lid. Injury to this muscle
would present as diplopia on upward
and lateral gaze.
ACKNOWLEDGMENT
The authors are grateful for the artistic contribu-
tions of Elan Horesh and Kriya Gishen.
SUGGESTED READINGS
Ellenbogen R. Transconjunctival blepharoplasty.
Plast Reconstr Surg. 1992;89(3):578.
Jelks GW, Jelks EB. Preoperative evaluation of
the blepharoplasty patient. Bypassing the
pitfalls. Clin Plast Surg. 1993;20(2):213–223;
discussion 224.
Mack WP. Complications in periocular reju-
venation. Facial Plast Surg Clin North Am.
2010;18(3):435–456.
Naik MN, Honavar SG, Das S, Desai S, Dhepe N.
Blepharoplasty: an overview. J Cutan Aesthet
Surg. 2009;2(1):6–11.
Wolfort FG, Kanter WR. History of blepha-
roplasty. In: Wolfort FG, Kanter WR, eds.
Aesthetic Blepharoplasty. Philadelphia, PA:
Lippincott, Williams & Wilkins; 1995:1–16.
 19
Brow lift

CHRISTOPHER J. SALGADO, TUAN TRAN, STEVEN SCHUSTER,

AND ELIZABETH YIM

Introduction 174 Preoperative markings 176

Coronal brow lift 174 Intraoperative details 176
Preoperative markings 174 Postoperative care 179
Intraoperative details 175 CPT coding 179
Postoperative care 175 Selected readings 179
Endoscopic brow lift 176

INDICATIONS

1. Desire to minimize the frown lines and 2. Repositioning of brow ptosis

prominent forehead creases to achieve 3. Reconstruction of significant facial paralysis
a youthful look involving brows and forehead

CONTRAINDICATIONS

1. Primary frontal alopecia 3. All other common surgical contraindications

2. Patient’s objection to altering or elevating the
hairline and loss of sensation

Table 19.1  Special equipment for open coronal brow lift

Scalpels
Mayfield horseshoe headrest
Cat claw retractors or coronal brow lift retractor
Ramey clips
Periosteal elevator
Multiple “peanuts” for dissection
21-gauge needle
(Continued)

173
174  Brow lift

Table 19.1 (Continued)  Special equipment for open coronal brow lift

Methylene blue
Preoperative IV antiobiotic consistent with Surgical Care Improvement
Project (SCIP) guideline
Sterile antiseptic skin preparation
Local anesthetic with 1:100,000 epinephrine
Additional options
Endotine multipoint fixation device and drill burr
D’Assumpcao marking clamp
Skin stapler

Table 19.2  Special equipment for endoscopic brow lift

5-mm rigid endoscope with 30° angle (2)
Mayfield horseshoe headrest
Blunt cobra tip (Deknatel-Snowden-Pencer) to provide elevation of overlying tissues
LCD monitor
Periosteal elevators, endoscopic cautery, and common plastic instrumentation
5.01 burr for drilling cortical tunnel
Preoperative IV antibiotic consistent with hospital antibiogram to cover
common gram-positive and gram-negative organisms
Sterile antiseptic skin preparation with Betadine® (Purdue Products, Stamford, CT)
Local anesthetic with 1:100,000 epinephrine

INTRODUCTION with fiberoptic magnification. Nevertheless, the

The face is the most important visible part of an
individual’s features. The first visible sign of aging
as well as elements of facial expressions are com-
municated via the face. The brow lift procedure is
usually performed to treat conditions of the face
associated with aging and facial paralysis. It may
be done separately or in conjunction with other
procedures to achieve a harmonious facial appear-
ance. There are varieties of brow lift procedures.
The open coronal brow lift has for years been con-
sidered the gold standard to which many other
procedures are compared. The endoscopic brow
lift, which was developed within the last 20 years,
is a viable but less invasive alternative.
The open coronal approach provides excellent
exposure for brow mobilization, lysis of adhe-
sions, and muscle excision to achieve the desired
brow elevation and shape enhancement. However,
the large incision and scalp excision increase the
risk of sensory changes and occasionally pro-
duce an unsightly scar. The advent of the endo-
scopic brow lift has minimized the scarring and
sensory loss while providing excellent exposure
endoscopic approach is limited with exposure,
­
inadequate elevation, and complete muscle exci-
sion. Plastic surgeons should be well versed in
both approaches (as well as other less invasive or
long-lasting minor procedures, i.e., direct supra-
brow excision) to apply the correct and appropriate
­technique to well-selected patients.
CORONAL BROW LIFT
Preoperative markings
1. Mark the anterior hairline, transverse f­ urrows,
glabellar frown lines, supratarsal crease, and
nasal root rhytides with the patient in the
upright position.
2. Identify and mark the supraorbital and
­supratrochlear nerves.
3. Mark the coronal incision 5 cm behind the
receding line or at the hairline with a sawtooth
incision.
4. If upper lid blepharoplasty will be performed,
the lids should be marked with the brow in the
anticipated final position.

Intraoperative details
1. The patient is taken to the operating
room and placed in a supine position.
The ­procedure can be performed under
­general anesthesia or monitor anesthesia
care. The neurosurgical Mayfield horseshoe
headrest or the “doughnut” is used to sup-
port the head.
2. Cleanse the hair and braid the hair to expose
the proposed incisions.
3. Shave a path approximately 1 cm anterior to
the proposed incision.
4. Infiltrate the brow area with local anesthetic
plus 1:100,000 epinephrine.
5. The patient is prepped and draped in standard
sterile surgical fashion.
6. Protect the corneas with corneal eye
shields, wet towels, or disposable sterile eye
protectors.
7. Incise the skin and subcutaneous tissue down
to the pericranium.
8. Carry the incision laterally to the root
of both ears to facilitate scalp and flap
mobilization.
9. Achieve hemostasis with Ramey clips.
10. Elevate and dissect in the subgaleal plane to a
point approximately 4 cm above the supraor-
bital ridge.
11. At this point, incise the periosteum from one
lateral aspect of the ridge to the other.
12. The periosteum is raised to just beyond the
ridge and onto the nose just beyond the radix
using a periosteal elevator.
13. Identify the previously marked superficial
deformities.
14. Flip the scalp back to its normal anatomic
position.
15. Mark the rhytides and creases with a 21-gauge
needle with methylene blue at the needle tip
and correlate these lines to the underlying
frontalis muscle.
16. Connect the dots.
17. Identify, mark, and preserve the supraorbital
neurovascular bundle.
18. Remove three to four thin strips of galea and
a portion of the frontalis muscle 1 cm above
and below the blue line.
19. Beware that too much resection of frontalis
muscle can leave unsightly depressions and
postoperative deformities.
Coronal brow lift  175
20. Leave 3 to 4 cm of intact frontalis muscle
above the supraorbital rim to preserve its
function.
21. The glabellar frown lines are also marked in
the same manner with methylene blue.
22. Identify the origins of the corrugator muscles,
which are found arising from the superome-
dial orbital rim.
23. Resect approximately 2 cm of corrugator
muscles to prevent reattachment.
24. If the patient has significant nasal root
wrinkles, the procerus muscle is disrupted in
a similar fashion to the corrugator.
25. Remember not to over-resect either the corru-
gator muscles or the procerus muscle to avoid
contour irregularities.
26. Achieve hemostasis.
27. Place the scalp back in its anatomic position.
28. Using two clamps, grasp the scalp edges; a line
is drawn from the lateral limbus of the eye.
29. Overcorrect the desired brow position by
1 to 1.5 cm.
30. Use the D’Assumpcao clamp to mark the
extent of resection bilaterally and in the
midline.
31. Tailor tack scalp edges and excise the overlap-
ping scalp edge.
32. In patients with a heavy brow or excess
ptosis, an Endotine fixation device may be
placed in the paramedian position as for an
endoscopic brow lift to support the brow in
the long term.
33. The galea is closed with interrupted 3-0
Vicryl® (Ethicon, Somerville, NJ) sutures.
34. The skin edges are closed with skin staples,
running 4-0 Prolene® (Ethicon) or 4-0 nylon
sutures with attention paid to everting the
edges.
35. The wound is dressed with nonocclusive
dressing, and topical antibiotics are applied
to wound edges to preclude the dressing from
sticking to the hair.
Postoperative care
1. Control blood pressure.
2. Pain control.
3. No bending over or heavy lifting for 10 days
postoperatively.
4. Cold compress applied to the eyes
continuously.
176  Brow lift
5. Patient may be discharged if criteria are met.
6. Patient is seen in 24 hours to check the wound
and change the dressing.
7. Patient can remove the dressing and shower
after 48 hours, using a gentle shampoo, and
apply a wide hair band as directed by the
­doctor to cover the wound.
8. Remove 3-0 nylon running sutures in the
office on postoperative day 7 or remove staples
at 10 days if used.
9. Patients are cautioned from using hair chemi-
cal, hair dryer, or curlers for 4 weeks due to
sensitivity and sensory loss in the central
scalp immediately postoperatively.
10. Obtain standard postoperative pictures in 3 to
4 months (Figures 19.1 to 19.3).
Figure 19.1  Right lateral view preoperative (left)
and postoperative (right) in 3–4 months.
Figure 19.2  Right oblique view preoperative (left)
and postoperative (right) in 3–4 months.
Figure 19.3  Frontal view preoperative (left) and
postoperative (right) in 3–4 months.
ENDOSCOPIC BROW LIFT
(FIGURES 19.4 THROUGH 19.12)
Christopher Salgado, Tuan Tran, and Elizabeth Yim
Preoperative markings
1. Mark the midline; mark the central parame-
dian access incision 2 cm from the midline
laterally and approximately 2 cm behind the
hairline.
2. Palpate the temporalis muscle and the t­ emporal
crest; mark an access incision (2–4 cm length)
horizontal incision behind the temporal hair-
line. Do this symmetrically for both sides.
3. Identify and mark the zygomaticotemporal
veins, “sentinel veins,” on both sides of the
forehead, the supraorbital nerve, and the supra-
trochlear nerve.
Intraoperative details
1. Ensure that all equipment is functional prior
to the patient entering operating room.
2. The patient is taken to the operating room and
placed in a supine position. The procedure
can be performed under general anesthesia or
local anesthesia with sedation.
3. Use a Mayfield horseshoe headrest for head
stabilization.
4. Cleanse and braid the hair to expose the
­proposed incisions.
5. Infiltrate the brow area with local anesthetic
plus 1:100,000 epinephrine in the subperios-
teal plane.

(a)  
Figure 19.4  (a) Frontal and (b) lateral views preoperative.
Figure 19.5  Preoperative markings.
6. Make an incision through both paramedian
vertex skin markings from the scalp directly
through the underlying periosteum.
7. Perform minimal periosteal undermining in
the surrounding area to mark the cranium
with electrocautery at the posterior aspect of
the incision (this will be the anterior, outer
cranial table drill hole).
8. Make an incision over the proposed tempo-
ral marking through the scalp down to the
superficial layer of the deep temporal fascia
overlying the temporalis muscle.
9. More significant subperiosteal dissection is
then performed at the cephalad incisions,
and an endoscope is inserted to visualize the
temporal crests in a subperiosteal fashion.
10. An elevator is used to free the area over the
superficial layer of the deep temporal fascia
around the incision.
Endoscopic brow lift  177
(b)
Figure 19.6  Lateral temporal access incision.
11. A blunt cobra-tip dissector is inserted through
the temporal incisions, and dissection is
performed toward the temporal line of fusion
connecting both optical cavities.
12. Identify and preserve the sentinel vein (medial
zygomaticotemporal vein).
13. Divide the septa and adhesions around the
sentinel vein and extend the dissection toward
the upper eyelid, deep to the orbicularis and
retroorbicularis oculi fat (ROOF).
14. Pull the brow upward to test and ensure all of
the attachments have been released and the
lateral brow is mobile.
15. Elevate the periosteum using a periosteal
elevator and the 30° angled scope with
retractor. Start the subperiosteal dissection
toward the glabella until a level approxi-
mately 2 cm above the supraorbital rim is
reached.
178  Brow lift

Figure 19.7  Placement of endoscope. Figure 19.8  Placement of dissector.

Figure 19.9  Dissecting under endoscopic Figure 19.10  Skin closure after central brow
guidance. fixation.

Figure 19.11  Temporal fixation. Figure 19.12  Early postoperative frontal view
with upper lid blepharoplasty.

16. Identify and preserve the supraorbital nerves,
which emerge through the supra­orbital foram-
ina bilaterally, in addition to the s­ upratrochlear
nerves and accompanied blood supply.
17. The periosteum is divided from one
­lateral orbital rim to the next. Visualize
the c­ orrugator, procerus, and depressor
­supercilli muscles and modify the muscles
by resection if desired by using endoscopic
grasper teasing and resecting the muscles
cephalad. (Note: Ensure that the patient
is kept h
­ ypotensive to avoid significant
bleeding.)
18. Hemostasis in the surgical bed may be
achieved with epinephrine-soaked pledgets.
19. Surgical drains via one of the four incisions
may be used if desired for 24 hours and are
removed on discharge.
20. Fixate the brow in the temporal area by
anchoring the temporoparietal fascia down to
the deep temporal fascia with sutures.
21. Brow fixation at the paramedian incisions
may be performed by performing a cortical
tunnel at 90° and suture placement through
the tunnel and fixed to the brow.
22. If performing a cortical tunnel, the first drill
hole should be placed at the posterior aspect
of the incision; 1 cm posterior to this hole,
the second one is made. (Use a 5-mm drill bit
for tunnel creation.)
23. Alternatively, brow fixation may be performed
with an external screw (a staple may be
placed behind the screw to maintain the brow
­position) or Endotine device.
Selected readings  179
Postoperative care
1. The patient may be admitted to the observa-
tion unit for 24 hours if there are confounding
medical comorbidities.
2. Elevate the head of the bed at 30° and place ice
packs over the eyes and brow.
3. Hypertension should be controlled to keep
systolic blood pressure below 120 mmHg
and ­diastolic blood pressure below 85 at all
times.
4. Remove any drains if less than 30 mL are
drained per 24 hours.
5. Advise the patient to keep the head elevated
and avoid any strenuous activities for 6 weeks.
CPT CODING
67900 Repair of brow ptosis (supraciliary, mid-
forehead, or coronal approach)
67999 Unlisted procedure, eyelids
SELECTED READINGS
De Cordier BC, de la Torre JI, Al-Hakeem MS,
et al. Endoscopic forehead lift: review of
technique, cases, and complications. Plast
Reconstr Surg. 2002;110:1558–1568.
Evans, G (2000) Operative Plastic Surgery.
Orange, CA: McGraw-Hill Professionals.
Withey S, Witherow H, Waterhouse N. One hun-
dred cases of endoscopic brow lift. Br J Plast
Surg. 2002;55:20–24.
 20
Facelift: The extended
SMAS technique

ARI S. HOSCHANDER AND JAMES M. STUZIN

Introduction 181 Notes 186

Markings 182 CPT coding 186
Intraoperative details 182 References 186
Postoperative protocol 186 Acknowledgment 186

INDICATIONS

1. Facial aging, including slack facial skin 4. Obliquity of cervical contour

2. Relaxed nasolabial folds 5. Facial fat descent with radial expansion of
3. Jowling the fat away from the facial skeleton

Table 20.1  Special equipment

Needle-tip bovie cautery Portable free-standing light
Lidocaine with epinephrine Rubber bands, small size
Methylene blue Bipolar cautery
Cotton-tip applicator Thimble retractor

INTRODUCTION address the global issues of facial aging. Facelifting

Rejuvenation of the aging face has taken many
turns over the last few decades. Most recently,
non-surgical rejuvenation with neuromodulators
and facial fillers has exploded in popularity. These
quick, short-term solutions are appropriate for
some patients and some problems, but they do not
procedures remain the best long-term answer to
the problem of facial aging. The extended super-
ficial musculoaponeurotic system (SMAS) tech-
nique for facelifting addresses and corrects many
of the problems that occur with facial aging.1
Issues and anatomic changes addressed during
this type of facelift procedure include skin laxity

181
182  Facelift: The extended SMAS technique

(­secondary to loss of elasticity), facial fat descent,

facial deflation, and radial expansion (facial fat no
longer adherent to the facial skeleton tends to fall
radially away from the face).
The extended SMAS technique involves rais-
ing both a skin flap and an SMAS flap. These two
flaps can then be repositioned in two different
vectors. The SMAS flap, along with the superfi-
cial facial fat, can then be redirected vertically,
repositioning into areas of deflation within the
lateral cheek. This restores fullness to regions
that have hollowed and removes bulging from
areas that should be contoured, such as the jowl.
The skin can then be pulled and redraped in a
more horizontal plane, providing a more natural
postoperative appearance. Lengthy discussions Figure 20.1  Retrotragal face-lift incision.
regarding facial fat descent, retaining ligaments
of the face, deflation, radial expansion, and the
role of skeletal support have been included in
previous texts. The fat compartments of the face
have similarly been well described previously in
articles and texts. 2
Knowledge of the detailed anatomy of the face
is imperative for performing both a safe and a
successful facelift. The focus of this chapter is to
provide a step-by-step guide to performing the
extended SMAS technique for facelifting. The goal
of this type of facelift is to provide the patient with
a long-lasting result of a more youthful and natu-
ral appearance. Table 20.1 provides a list of special
equipment needed.
Figure 20.2  Postauricular extension of facelift
MARKINGS incision.

1. A line is drawn from a point just lateral to the

lateral canthus and extending caudally toward
the body of the mandible. This line should be
parallel to the anterior border of the masseter.
This will mark the medial extent of the subcu-
taneous dissection.
2. Another line is drawn starting within the
hair-bearing scalp of the temporal region
and extending inferiorly, anterior to the ear,
within the tragus, to the inferior aspect of the
ear (Figure 20.1). This intratragal incision will
help avoid the telltale sign of a facelift, namely
color difference between the tragus and the
cheek. This line is then carried under the lob-
ule, then up and behind the ear, in the vertical
direction within the junction of the posterior
concha and the postauricular skin (i.e., the
conchal groove). The line takes a right-angle
turn posteriorly at the point where the concha
meets the hairline, and the line extends into
the hair-bearing scalp of the occipital region.
Finally, this line takes a gentle curve postero-
inferiorly within the hair-bearing scalp
(Figure 20.2).
INTRAOPERATIVE DETAILS
1. It is helpful to place the patient’s hair into
bundles secured with individual rubber
bands.
2. The face is prepped and draped in the usual
fashion with Betadine® (Purdue Products,
Stamford, CT) paint.
 Intraoperative details  183

3. Lidocaine 0.5% with epinephrine is instilled dissection inferior to the line. Using the
along the incision lines and the planes of back end of a cotton-tip applicator dipped
­subcutaneous dissection. in methylene blue, a line from the tragus to
4. The skin is incised through the predrawn the eyebrow overlying the SMAS is drawn.
intratragal incision extending into the tem- Cranial to this line is the area where the
poral scalp. Of significant importance is the frontal nerve will begin to course more
preservation of the incisura of the tragus, superficially, and staying caudal to this line
the junction of the inferior-most aspect of the will ensure its safety.
tragus with the cephalad-most portion of the 10. The next line that is drawn is a line 1 cm
earlobe. inferior and parallel to the zygomatic arch.
5. Using skin hooks, the skin is retracted, and At the point where the zygomatic arch meets
the dissection is begun with a #15 blade the body of the zygoma, an extension of this
­scalpel and then sharp scissor dissection. line is carried at approximately 45° toward
Special care and meticulous attention are paid the lateral canthus and overlying the malar
to this dissection to ensure even flaps that are eminence for approximately 3–4 cm. This
not too thick or too thin. The use of a free- is the cranial-most extent of the SMAS
standing portable light source is helpful for dissection.
transillumination of the other side of the skin 1 1. A vertical line is drawn along the SMAS
flap to show the interface between subcutane- paralleling the original skin incision from
ous fat and the SMAS. It is important not to the zygomatic arch inferiorly along the lateral
dissect deep to the SMAS, or it will be difficult border of the platysma. This line begins at the
to raise an adequate SMAS flap later. It is lateral-most aspect of the previously drawn
equally important not to make the skin flaps line (1 cm inferior to the zygomatic arch) and
too thin, lest they should be prone to venous continues vertically and inferiorly along the
congestion. posterior border of the platysma, approxi-
6. The superficial temporal artery splits into the mately 5–6 cm below the mandibular border
parietal and frontal branches. The parietal (Figure 20.3).
branch is then identified and ligated at its
takeoff. The temporal dissection is carried
directly superficial to the deep temporal
fascia.
7. The subcutaneous dissection is now carried
caudally toward the neck. At this point, the
skin flap can be left a little thicker than its
more cranial counterpart. Note that the great
auricular nerve lies beneath the SMAS along
the mid-belly of the sternocleidomastoid
­muscle. This dissection is continued caudally
over the angle of the mandible and further
down into the neck overlying the platysma.
The dissection is carried medially into the
anterior neck forward through the submental
incision, which will be incised later in the
procedure.
8. Returning to the malar region, the subcuta-
neous dissection is continued until the skin
is freed from the restraint of the zygomatic
ligaments, toward the lateral canthus.
9. The SMAS dissection commences by first Figure 20.3  Representation of areas for subcuta-
marking the path of the frontal branch neous undermining (solid line) and SMAS incision
of the facial nerve, keeping the SMAS (dotted line).
184  Facelift: The extended SMAS technique
12. Now, the incision line in the SMAS and
the plane beneath the SMAS are infiltrated
with a solution of 0.5% lidocaine containing
epinephrine.
13. The SMAS may now be incised with a
#10 scalpel. The SMAS is reflected medially
with forceps with teeth, and the dissection is
begun on the undersurface of the SMAS with
a combination of sharp and electrocautery
dissection. Keeping the dissection superficial
to the parotid capsule and deep facial fascia
is critical to prevent a facial nerve injury.
Dissecting directly along the undersurface of
the SMAS and ­leaving the sub-SMAS fat on
top of the deep facial fascia protects underly-
ing facial nerve branches.
14. This sub-SMAS dissection is carried medially
until the zygomaticus major is encountered, and
the SMAS is freed from the lateral zygomatic
eminence superficial to the zygomaticus major.
15. Often, the SMAS is not yet completely mobile
at this point, and the sub-SMAS dissection
needs to be carried further medially in the
malar region. This is done by inserting scis-
sors in the plane between the malar fat pad
and the elevators of the lip. The scissors are
used to bluntly dissect in a direction aiming
toward the nasal ala. Of note, this is an area of
SMAS dissection that does not have a skin flap
dissection overlying it (Figure 20.4).
Figure 20.4  Sub-SMAS dissection.
16. Now that the SMAS layer is free and mobile,
it can be repositioned into a location that
brings the facial fat pads superiorly into the
regions of lateral cheek deflation. The direc-
tion of pull is vertical (Figure 20.5).
17. Now, if malar augmentation is deemed neces-
sary, any SMAS that has been displaced supe-
riorly and extends above the zygomatic arch is
folded under itself to augment the malar emi-
nence. If malar augmentation is not planned,
then the remaining SMAS extending above
the zygomatic arch is incised and discarded.
In either case, the SMAS is split at the point that
it overlaps the lobule of the ear, allowing some
SMAS to be secured anterior and some SMAS
to be secured posterior to the ear. The SMAS is
then secured in this location with a soft absorb-
able suture, down to the underlying tissue and
periosteum of the zygomatic arch (Figure 20.6).
18. The preceding steps are repeated for the oppo-
site side of the face.
19. Next, a submental incision is made in a crease
5 mm caudal to the submandibular crease.
20. The dissection is carried out in a subcutane-
ous plane until the subcutaneous dissec-
tions from either side of the face meet. It is
important to keep and preserve 5–6 cm of
preplatysma fat on the skin flap. Following
through-and-through neck dissection, excess
cervical fat is sharply contoured with scissors.
Figure 20.5  SMAS redraping with vertical vector
of pull.
 Intraoperative details  185

Figure 20.6  Technique of SMAS suturing.

Figure 20.7  Medial repositioning of the platysma
and platysmal myotomy.

This dissection is aided by the use of a lighted

retractor.
21. At this point, the platysma muscle can be
visualized and may need to be repositioned
and sutured together if it has splayed in
the midline.
22. Next, the freed medial edges of platysma
are grasped and brought toward the midline
to assess redundancy. Any excess platysma
should be resected.
23. The medial edges of the platysma muscles can
be sutured together in the midline. Attempts
to place these sutures through the muscular
fascia should be made.
24. Now, an incision can be made that t­ ransects
the medial portion of the p­ latysma i­ nferiorly.
This allows the platysma to redrape itself in
Figure 20.8  Skin redraping with a horizontal
a more anatomic and youthful position and
­vector of pull.
removes tension on the platysmaplasty. This
partial platysma myotomy is performed in
the lower neck, usually from a dissection of Using a #15 scalpel, the skin flap is incised
5–6 cm on each side of the platysma, and is in the temporal region, and key sutures are
performed distal to the hyoid (Figure 20.7). placed. A similar key suture is placed in the
25. A small suction drain is placed into the neck, postauricular region (Figure 20.9).
exiting the skin incision behind the ear. 28. The skin is now draped over the tragus, and
26. After achieving meticulous hemostasis, the the line of resection is determined. It is usu-
neck incision can be closed with 6-0 nylon ally a rectangular resection and should be
suture in a simple, interrupted fashion. made with very sharp corners and some skin
Hemostasis cannot be overstated. This will redundancy. This redundancy will help to
reduce both postoperative hematoma and prevent postoperative contraction around the
edema. tragus and subsequent external meatal “show.”
27. The skin is now redraped, and the amount 2 9. All incisions are closed with 4-0 and
to be resected is determined (Figure 20.8). 6-0 nylon suture.
186  Facelift: The extended SMAS technique
Figure 20.9  Key suture placement for skin
closure.
30. Fat grafting can be performed at this time if
deemed necessary preoperatively.
31. The face is cleaned, and the hair is washed.
A bulky head dressing is applied.
POSTOPERATIVE PROTOCOL
Patients are kept in the post-anesthesia care unit
for a period of observation. They may be dis-
charged home if they are tolerating liquids and
are not nauseous. Patients should be advised to
keep ice packs to the face, avoid any strenuous
activity, keep the head of their bed elevated at
all times, keep pressure off incisions, and keep
bandages dry. Patients should be seen by the sur-
geon on postoperative day 1, and bandages can
be removed at that time. The drain stays in place
until p
­ ostoperative day 3 or 4, when its output is
assessed and it can be removed by the surgeon.
NOTES
Many surgeons use different techniques to reposi-
tion the descended facial fat, specifically relating to
the handling of the SMAS, but the advantage of the
extended SMAS technique is aesthetic versatility.
Other adjunctive procedures can be added to this
operation, including, but not limited to, upper and
lower lid blepharoplasties, fat augmentation, and
laser resurfacing.
CPT CODING
15829 Rhytidectomy; superficial musculoaponeu-
rotic system (SMAS) flap
REFERENCES
1. Stuzin JM, Baker TJ, Gordon HL, Baker TM.
Extended SMAS dissection as an approach
to midface rejuvenation. Clin Plast Surg.
1995;22(2):295–311.
2. Rohrich RJ, Pessa JE. The fat compartments
of the face: anatomy and clinical implica-
tions for cosmetic surgery. Plast Reconstr
Surg. 2007;119(7):2219–2227.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 21
Rhinoplasty

TARA E. BRENNAN, THOMAS J. WALKER, AND DEAN M. TORIUMI

Introduction 188 Considerations in grafting 194

Nasal analysis 188
Patient discussion, goals 188
Facial analysis, nasal analysis, profile alignment 188
Nasal osseocartilaginous skeletal analysis 190
External rhinoplasty: Intraoperative details 190
Preoperative documenting, marking, injecting 191
Incision planning and execution 191
Elevation of skin and soft tissue envelope 191
Dorsal hump reduction 191
Osteotomies 192
Septoplasty 193
Advanced maneuvers in external rhinoplasty 194
Management of the middle nasal vault 195
Nasal tip surgery 195
Closure 197
Nasal packing/septal splints 198
Nasal sidewall splints 198
Dorsal splint 198
Postoperative details 198
CPT coding 198
References 199

INDICATIONS

1. Cosmetic or functional nasal deformity 3. Nasal valve support or repair

2. Congenital or acquired nasal deformity 4. Nasal septal reconstruction

Table 21.1  Special equipment

Scissors: Converse scissors and suture scissors
Retractors: Converse retractor; Neivert retractor; double-prong skin hooks, small/narrow/medium/
wide; dull skin hooks; Cottle hook; nasal specula, small/medium/large; black small nasal speculum
Forceps: Adson Brown, Adson with and without teeth, Takahashi forceps, 5-inch Bayonet, Bishop
Harmon curved, bone fixation and straight, 4½-inch rat tooth forceps, Adson and Bayonet Bipolar
Forcep non-stick with cord
Osteotomes/elevators: straight unguarded osteotomes, 2, 3, 4, 5 mm; straight guarded osteotome,
3 mm; Rubin osteotome 14, 16 mm; Joseph elevator; Cottle elevator; Freer elevator; suction elevator;
rasps, delicate/coarse; rasp ball tip; Maltz/Parkes rasp; Xomed diamond rasp; Boise elevator
Miscellaneous: mallet with nylon head, cartilage crusher, cartilage board, Caliper, metric ruler, #3 and
#7 knife handles, Castroviejo needle holders, Webster needle holders, curved Mosquito clamps, Allis
clamp, Frazier suction tips, stylet, small penetrating and non-penetrating towel clips, Crile hemostat

187
188 Rhinoplasty
INTRODUCTION
Rhinoplasty is considered to be one of the most
challenging operations in facial plastic and recon-
structive surgery.1 Nasal anatomy varies widely
among different races and between ­genders. Nasal
anatomy also naturally changes with age, and trau-
matic or surgical alterations to the nose affect this
evolution. Rhinoplasty surgeons observe that the
appearance of the operated nose at one week dif-
fers greatly from its appearance at one month, one
year, three years, and six years after an operation.
Over time, it becomes more apparent that main-
taining structural support to the nose is para-
mount to its long-term cosmetic appearance and
function.
In the sections that follow, we highlight the meth-
ods of nasal analysis, profile alignment, m
­ anagement
of the upper two-thirds of the nose and nasal tip, and
septoplasty. The approach to  external rhinoplasty
is outlined as well. Table  21.1 lists the equipment
needed for external rhinoplasty.
NASAL ANALYSIS
Patient discussion, goals
Comprehensive preoperative analysis begins with
a detailed discussion with the patient. It is impera-
tive to understand the patient’s cosmetic and func-
tional goals for the operation and interpret them
in light of a holistic facial analysis. Changes made
during rhinoplasty should remain in harmony
with the rest of the face. In addition, patients
should be educated about the balance required
between reductive maneuvers, if desired, and
the maintenance of adequate skeletal support to
maintain good cosmetic and functional long-term
outcomes.
Facial analysis, nasal analysis,
profile alignment
Analysis of the nose must be done in the context of
analysis of the rest of the face. A holistic approach
should be used, taking into consideration the
patient’s age, ethnicity, skin thickness, and goals
for surgery.
Facial analysis begins with good photography,
including frontal, oblique, lateral, and base views
of the patient.2 High-quality, consistent photog-
raphy is paramount to both patient education and
satisfaction in the pre- and postoperative time
periods. Computer imaging can be helpful to
ensure that patient and surgeon goals are in line
preoperatively. Good photography also assists the
surgeon in analyzing his or her results over time.
The frontal view is arguably the most impor-
tant; it represents how one is seen by others and
how a patient will critically analyze his or her rhi-
noplasty result in a mirror.2 Assessment of overall
nasal length, width, rotation, symmetry, and devi-
ation is paramount in this view, as is assessment
of the brow-tip aesthetic line.3 The appearance
of the nasal tip has much to do with shadowing
and contours created by its underlying osseocar-
tilaginous skeletal structure.2,4 The ideal nasal tip
has a smooth contour and is continuous laterally
with the alar rims. Nasal tip pinching may be pre-
vented by maintaining good structural support
to the nasal tip, with placement of alar rim or lat-
eral crural strut grafts (LCSG) as needed to sup-
port the smooth contour of this area5 (Figures 21.1
and 21.2).
Figure 21.1  Favorable nasal tip contour has
a horizontal orientation, with a shadow in the
supratip area that continues into the supra-
alar regions. The transition from the tip lobule
to the alar lobule is smooth, without a line of
­demarcation. The tip-defining points are seen
as a horizontally oriented highlight with shadows
above and below. (From Toriumi DM, Checcone
MA. Facial Plast Surg Clin N Am. 2009;17:55–90.)
 Nasal analysis  189

(c)

(a)

(b)

Figure 21.2  On the oblique view (a), a favorable tip contour demonstrates a subtle supratip break
shadow that continues into the supra-alar groove. These shadows represent narrowing as the tip
­transitions into the supratip and middle nasal vault. On lateral view (b), the tip projects above the
dorsum slightly, highlighting a subtle supratip break. A more refined tip may be created by l­owering
the position of the supratip break. The base view (c) shows a triangular shape. No notching is seen
between the tip lobule and the alar lobule. Also note the horizontal component of the nasal tip.
(From Toriumi DM, Checcone MA. Facial Plast Surg Clin N Am. 2009;17:55–90.)

When analyzing lateral view photographs, nasal

profile alignment is a central focus. Nasal projec-
tion relative to the forehead and chin is analyzed.
For example, an underprojected chin makes the
nose appear larger. A chin implant may comple-
ment a rhinoplasty in these patients (Figure 21.3).
A lower nasofrontal angle also may make the
nose appear shorter. In these cases, radix grafts
may be employed to make the nose appear longer
(Figure 21.4).
The base view allows one to analyze the nostrils
for symmetry, shape, and size. The position of the
caudal nasal septum is noted. The width of the
nasal base is assessed. The columella-lobule ratio is
noted. The medial crural footplates are assessed for Figure 21.3  Before and after chin implant (with
rhinoplasty involving conservative dorsal hump
shortened length or flaring. The lower lateral carti-
reduction).
lages (LLCs) are assessed for weakness and recur-
vature. The degree of external nasal valve collapse difficult to redrape over the nasal skeleton and
is assessed on inspiration. ­create a refined look.
Skin thickness has several important implica- Special care should be taken to not overreduce
tions with respect to surgical planning. Medium- the nasal framework in thick-skinned patients.
thickness skin is the most ideal with respect to Failure of thick skin to favorably contract over an
surgical outcomes: Thin skin will fail to mask sub- excessively reduced framework may result in an
tle contour irregularities in the underlying nasal amorphous, “pollybeak” tip of redundant soft tissue
skeleton, and thick, sebaceous skin may prove (Figure 21.5). It is wise to counsel these patients that
190 Rhinoplasty
Figure 21.4  A radix graft softens the ­nasofrontal
angle and makes the nose appear longer and
more balanced.
Figure 21.5  Pollybeak deformity on lateral view.
to make their nose appear narrower on frontal view,
one may need to augment the d ­ orsum and p­ roject
the tip, leaving them with a bigger framework over
which their thicker skin may be stretched and
refined as it is redraped. In some cases, conservative
subcutaneous tissue thinning may be performed.
Thin-skinned patients have the opposite problem.
Thin-skinned individuals have a limited soft tissue
cushion and therefore limited ability to conceal
underlying skeletal framework irregularities or con-
tour imperfections. Thin-skinned patients are also at
risk for more progressive skin contraction over time.1
Patients who have had prior surgery or synthetic
material placed in their nose tend to have skin that
is more devascularized and thinned. Extra care
must be dedicated to dissection and elevation of
the skin soft tissue envelope in these patients.
Nasal osseocartilaginous
skeletal analysis
Analysis of the nasal framework is accomplished
by photography, palpation, and endoscopic exami-
nation. The amount of nasal septal cartilage should
be noted for preoperative planning purposes.
Patients deficient in septal cartilage should be
counseled that a secondary donor site (ear or rib)
may be required to harvest cartilage for grafting.
Particular attention should be paid to the inter-
nal nasal valve, a common source of nasal obstruc-
tion. Made up by the nasal septum, the caudal
border of the upper lateral cartilages (ULCs),
and the head of the inferior turbinates, hypertro-
phy or malposition of any one of these structures
may result in symptomatic narrowing and nasal
obstruction. Internal nasal valve collapse may be
improved by straightening the septum, reducing
the inferior turbinates, strengthening the nasal
sidewalls, or placing spreader grafts. The angle
between the septum and nasal sidewall (ULC)
should be at least 15°.
The dorsum of the nose consists of the nasal
bones, the dorsal septum, and the ULCs. Longer
nasal bones are advantageous to a patient under-
going rhinoplasty because they confer additional
support to the middle vault. These patients are less
likely to suffer from middle vault collapse after dor-
sal reduction and are less likely to require spreader
grafts to prevent this complication.6 Having uniform
bony and cartilaginous widths is desirable as this
contributes to a smooth brow-tip aesthetic line.
EXTERNAL RHINOPLASTY:
INTRAOPERATIVE DETAILS
Deciding whether to perform an endonasal versus
an external approach for rhinoplasty depends on
the planned maneuvers of the operation.
The endonasal approach is ideal among patients
whose operations will require limited grafting,
as this approach does not involve a visible inci-
sion on the columella, involves less soft tissue
 External rhinoplasty: Intraoperative details  191

dissection, and results in less postoperative nasal

edema. A variety of endonasal incisions may be
used to access the osseocartilaginous framework
of the nose for reductive or grafting maneuvers.
Marginal incisions may be used in these cases to
place alar rim or batten grafts. Intracartilaginous
incisions may be used to cephalically trim the
LLCs. Marginal and inter-­cartilaginous incisions
may be used to deliver the LLCs for manipulation,
tip suture placement, and grafting.
The external rhinoplasty approach works well
in patients who require more complex cartilage
grafting and those noses that demonstrate signifi-
cant asymmetries or complex deformities. More
advanced techniques for septal reconstruction,
including caudal septal replacement grafts, may
also be exercised with the wide exposure afforded
by the external approach.7 This chapter focuses
primarily on the external rhinoplasty approach.

Preoperative documenting, Figure 21.6  Columella and marginal incisions

marking, injecting
Once the detailed preoperative planning, pho-
tographic analysis, and operative planning have
taken place, intraoperative photographs (frontal,
lateral, and base views) are taken. Next, contour
irregularities and deviations are marked, fol-
lowed by injection of a local anesthetic solution
containing epinephrine for hemostasis, antibi-
otic administration, and skin cleansing for sur-
gery. It  is  helpful to trim the nasal vibrissae to
allow clear visualization of the landmarks noted
in making intranasal incisions.
Incision planning and execution
For external rhinoplasty, the operation begins
with making an inverted V transcolumellar inci-
sion with a #11 blade, taking care not to violate
the underlying cartilage. Placement of the inci-
sion is important, with usual placement at the
mid-columella.
Elevation of skin and soft
tissue envelope
The columellar incision is then connected to bilat-
eral marginal incisions made at the caudal aspect
of the LLCs. When raising the columellar flap,
care must be taken not to inadvertently injure the
are connected to elevate the skin soft tissue
­envelope in the external rhinoplasty approach.
underlying medial crura, which are positioned
immediately underneath the skin at the lateral
aspect of the columella (Figure 21.6).
Next, the skin soft tissue envelope is elevated
sharply off the LLCs using Converse scissors.
Dissecting as close as possible to the cartilage itself
helps to preserve the subdermal plexus of the skin
soft tissue envelope. Elevation continues off the
underlying ULCs and osseocartilaginous pyramid
in a similar fashion. Over the bony vault, a Joseph
elevator is used to create a subperiosteal tunnel.
A  tight pocket should be created if one plans to
place a dorsal or radix graft.
Dorsal hump reduction
If the patient requires a dorsal hump reduction, this
should be performed prior to removing ­cartilage
during the septoplasty. Addressing any dorsal
­
irregularities and performing osteotomies prior to
removing the deviated portions of the nasal septum
provides maximal stability of the osseocartilaginous
junction of the septum during these maneuvers.
The cartilaginous hump reduction is per-
formed with a #15 scalpel blade. The osseous
hump is removed en bloc using a Ruben osteo-
tome (Figure  21.7). It is important to avoid
192 Rhinoplasty
Figure 21.7  The dorsal hump is removed en bloc.
The cartilaginous component is taken down using
a #15 blade and the bony component with an
osteotome.
extending the osteotomies too superiorly as this
may inadvertently reduce the radix. If a large
dorsal hump reduction is planned, it is also help-
ful to first elevate the dorsal aspect of the muco-
perichondrial flap from the undersurface of the
ULCs so that it is not inadvertently torn as the
hump is removed.
After osteotomies are completed, additional
dorsal bone may be shaved and the nose shaped
using a rasp. In many cases, a rasp can be used to
take down the entire dorsal hump. A downside to
this approach is that extensive rasping can result in
increased postoperative ecchymosis.
Osteotomies
Osteotomies are performed to mobilize deviated
nasal bone segments and move them into a more
favorable, narrower position (Figure 21.8).
Medial osteotomies are often necessary to mobi-
lize the medial portion of the nasal bone, espe-
cially if no or limited dorsal hump reduction was
performed. A 3-mm straight osteotome, guarded
or unguarded, may be used to perform an osteot-
omy, starting just off midline of the osseous nasal
Medial
Lateral
Intermediate
Figure 21.8  Depicted here are medial, lateral,
and intermediate osteotomies. Note that an
approximate 5-mm osseous bridge separates
the medial and lateral osteotomies on each side
for stability of the nasal bones. After comple-
tion of bilateral medial and lateral osteotomies
with a ­ dequate mobilization of the interven-
ing nasal bone segments, the bony vault
appears narrowed, casting favorable shadows
along its sidewall. Intermediate osteotomies
are s­ ometimes used and serve to correct
severe nasal bone ­concavities or convexities,
severe nasal ­deviations, or significant differences
in nasal bone lengths between opposite sides.
Intermediate osteotomies are performed after
medial but prior to lateral osteotomies.
vault and advancing superiorly, fading obliquely/­
laterally while moving toward the medial canthus
to avoid the thick frontal bone in the midline.
Using an unguarded osteotome causes less trauma
to the intranasal mucosa but requires experience
to keep it on its intended path during execution
of the osteotomy. Gentle rasping can be performed
to make sure there are no spicules of bone along
the osteotomy site (Figure 21.9).
After completing the medial osteotomies, lat-
eral osteotomies can be performed. The lateral
osteotomy typically begins high on the piriform
aperture and then passes low or lateral on the
ascending process of the maxilla to end higher or
medially at the level of the medial canthus. This
path will preserve a triangle of bone near the base
of the piriform aperture, preventing medialization
of the inferior turbinate and excessive narrow-
ing of the airway (Figure 21.10).

Medial osteotomy
Figure 21.9  The medial osteotomy is performed
with a 3-mm straight unguarded osteotome
placed at the rhinion parasagitally near the
­junction of the osseous septum and the nasal
bone. The medial osteotomy should slightly fade
15° to 20° off midline to avoid cutting into the
nasofrontal area.
In some cases, it may be necessary to perform
percutaneous osteotomies to complete an incom-
plete osteotomy. In this case, a 2- or 3-mm straight
osteotome is advanced through the skin along the
path of the lateral osteotomy, making m ­ ultiple post-
age stamp–type perforations in the bone  through
a single entry site. This maneuver precisely cuts the
bone, allowing the nasal bones to be medialized.
Some surgeons use percutaneous osteotomies rou-
tinely to perform their osteotomies. Rarely does the
puncture site cause any scarring.
Septoplasty
Septoplasty is often indicated for functional or
cosmetic purposes or for obtaining cartilaginous
material for grafting. One may make a Killian,
hemitransfixion, or transfixion incision to access
the plane for nasal septal mucoperichondrial flap
elevation.
If one is planning on dissecting the medial
crura of the LLCs from the nasal septum for future
maneuvers in the operation (i.e., placement of caudal
External rhinoplasty: Intraoperative details  193
Lateral osteotomy
Figure 21.10  The lateral osteotomy begins high
on the pyriform aperture and passes lateral on
the medial maxilla to end medially at the height
of the medial canthus.
septal extension graft, lateral crura ­repositioning,
or tip deprojection-reprojection maneuvers), one
may dissect between the medial crura to gain direct
access to the anterior septal angle and nasal sep-
tum. This  approach is also helpful if one plans to
perform  more formal anterior septal reconstruc-
tion for a caudally deviated nasal septum. This inci-
sion,   however, affects a major source of nasal tip
support, and the tip must be properly re-­supported
at the conclusion of the operation to prevent
destabilization.
If no direct access to the caudal septum is neces-
sary, a Killian or hemitransfixion incision may be
utilized to access the nasal septum, which will keep
the septoplasty and rhinoplasty dissections inde-
pendent of each other and preserve a major source
of nasal tip support. A hemitransfixion incision is
placed at the caudal margin of the nasal septum and
is helpful in addressing caudal septal deviations.
If access to this point is not necessary, a Killian
incision, made further posteriorly, is preferred.
Elevation of the flaps should be easy and bloodless
and may be accomplished with a Freer elevator,
alone, in most cases; if not, it is usually because one
is not in the correct plane. It is important to avoid
tears in the mucoperichondrium, particularly
194 Rhinoplasty
apposing tears, as this may result in postoperative
nasal septal perforation (Figure 21.11).
After the mucoperichondrium is elevated on the
side of the incision, an incision is made through
the cartilage with a #15 blade to allow elevation of
the mucoperichondrium on the contralateral side
of the septum. Marking out a 1.5-cm L-shaped sep-
tal strut is important prior to making this incision
in the cartilage. Deviated portions of septal carti-
lage can be removed as long as this strut is left intact
to avoid a postoperative saddle nose deformity.
Deviated bony septal components may need to be
removed as well, but this should be done without
destabilizing the ethmoid bone superiorly to avoid
creating a cerebrospinal fluid leak. Occasionally,
the L strut may be significantly compromised or
deviated and need to be removed. In these cases,
the L strut may be reconstructed with grafts, often
using costal cartilage to confer adequate strength
and stability to the nasal framework.
Removing obstructing bony spurs along the
maxillary crest may be done in a conservative
fashion, as overly aggressive reduction may result
in hyperesthesia of the maxillary teeth. Osseous
spurs may be trimmed tangentially using a 5-mm
straight osteotome or using a rotating power burr.
Alternatively, the spur may be shifted toward the
midline using an osteotome and stabilized with a
suture.
Considerations in grafting
Septal cartilage that is not used as grafting material
should be straightened and placed back between
Figure 21.11  Here, a Killian incision is made using
a #15 blade, and the nasal septal flap is elevated
in a bloodless, submucoperichondrial plane using
a Freer elevator.
the septal mucoperichondrial flaps. Alternatively,
it may be banked in the hair-bearing scalp behind
the ear in the event minor nasal revision surgery
is required. Cases that require additional grafting
material may need costal or auricular cartilage
harvest.
Advanced maneuvers in
external rhinoplasty
At this point, the surgeon decides if advanced
maneuvers will be required for nasal septal recon-
struction, dorsal augmentation, or lateral nasal
wall strengthening.
Caudal septal extension grafts (fashioned from
harvested septal cartilage or another source)
may be used to set tip projection, rotation, naso-
labial angle, caudal septal length, and columel-
lar show. Septal extension grafts may be sutured
to the native caudal septum (if midline) in an
end-to-end fashion with splinting grafts (extended
spreader grafts or cartilage slivers) or PDS plates
(Mentor Worldwide, Santa Barbara, CA) to confer
­additional strength (Figure 21.12).
Figure 21.12  Caudal septal extension graft
placed end to end with the native caudal
septum. The graft is stabilized by extended
spreader grafts running along either side of the
native septum and extending to sandwich the
caudal septal extension graft as well. Interrupted
5-0 PDS sutures are placed to stabilize this
neo-L strut complex. Also pictured are 0.25-mm
PDS plates, providing additional stability to the
caudal septum. The medial crura are then fixed
to the caudal extension graft using 4-0 plain
gut and 5-0 PDS sutures. (From Toriumi DM,
Checcone MA. Facial Plast Surg Clin N Am.
2009;17:55–90.)

Resorbable 0.25 mm  PDS plates may also be
used to splint a high septal deviation midline. In
these cases, resorbable PDS plates may be used to
confer stability to a newly straightened L strut by
splinting at the “elbow” of the L strut. PDS plates
are typically resorbed within 6 months and should
be covered by an intact mucoperichondrial flap.7,8
Dorsal augmentation is another advanced
maneuver and may be used to improve saddle nose
deformity for cosmetic or functional purposes if
the underlying dorsal septal support is inadequate.
In most of these cases, costal cartilage harvest is
required given the volume of cartilage needed for
these reconstructive cases.
Management of the middle
nasal vault
After dorsal hump reduction, the ULCs may need
to be stabilized to prevent inferomedial collapse
(also known as the inverted V deformity). Patients
with short nasal bones are at higher risk for this
deformity, which may be prevented by placing
spreader grafts between the ULCs and the dorsal
nasal septum that extend from the nasal bones to
the nasal valve region close to the anterior septal
angle9 (Figure  21.12). Typical spreader grafts are
2 to 3 mm thick and should be 3 to 4 mm in verti-
cal height. If the spreader grafts are too tall, they
can block the internal nasal valve. If too wide, they
may cause inadvertent lateralization of the nasal
bones.
Nasal tip surgery
The nasal tip is unique in that it is physiologically
dynamic, moving with inspiration, expiration, and
facial expression. Maintenance of its structural
support is paramount. These concepts are particu-
larly important when considering the functional
role of the nasal tip in maintaining the integrity of
the nasal airway. Affecting the shape, orientation,
and strength of the lower lateral crura may confer
additional stability to the nasal tip.
As discussed previously, the appearance of
the nasal tip is very much dependent on shadow-
ing effects created by the shape and orientation of
the lower crura rather than the degree to which
it is narrowed. The favorable nasal tip contour is
horizontal in orientation, with a shadow in the
supratip area that continues into the supra-alar
External rhinoplasty: Intraoperative details  195
regions, a subtle supratip break noted on oblique
and lateral views, and a tip that does not appear
notched on base view (Figures  21.1 and 21.2).
Importantly, maneuvers performed to affect the
nasal tip should strive to attain a look that is
­natural. Over-resection or over-­narrowing often
creates a “­surgical” or over-done look.
The appearance of a “ball tip” is a common defor-
mity of the nasal tip involving pinching between the
dome and alar rims bilaterally and narrowing in the
supratip and infratip regions. These contour irregu-
larities create an outline around the nasal tip, creating
the look of a ball tip.2,10 Although it may seem coun-
terintuitive, the creation of a ­ narrower-appearing
nasal tip may involve the addition of horizontally
oriented cartilage grafts to the nasal tip area to create
more favorable shadowing and contours.
Attention should be paid to the nasal base, which
should be well supported by the medial crura. One
should consider the relationship of the medial crura
to the caudal septum, as well as the strength of this
attachment. The caudal nasal septum should be
straight, as this determines alignment of the nasal
tip. Patients with a hanging columella or excessive
caudal septal show may benefit cosmetically from
medial crura setback and suturing onto the septum
with 5-0 PDS suture. This may affect the tip projec-
tion, alar-columellar relationship, and rotation.
A sutured-in-place columellar strut may con-
fer additional stability to the nasal base. This graft
should be placed between the medial crura after
dissecting the intercrural soft tissue attachments to
make a narrow pocket to accommodate the graft. In
the vast majority of our cases we place an end-to-end
caudal septal extension graft stabilized with bilateral
extended spreader grafts. This provides excellent
support to the nasal tip. Patients who have a severely
deficient nasal base or premaxilla may benefit from
augmentation of the premaxilla or an extended colu-
mellar strut graft fixed directly to the nasal spine.
There are many options for nasal tip contouring.
In most cases, the initial tip-refining maneuver is
to perform a cephalic trim of the lateral crura. The
amount of cartilage removed should be minimal to
preserve support. As a guideline, in most patients
8 to 10 mm of lateral crus should be left laterally.
As  one moves medially toward the domes, 6 to
8 mm should be left.
Another workhorse maneuver for narrow-
ing the nasal tip is the dome suture. One type of
dome suture is a horizontal mattress suture that
196 Rhinoplasty

Alar Rim
Grafts

(a) (b) (c)

Figure 21.13  (a) Two separate 5-0 clear nylon dome sutures are placed to narrow the dome angle.
Aninterdomal suture is then placed to set the width between the two newly narrowed domes. (b) Some
pinching occurs with this maneuver, which can be smoothed by placing alar rim grafts between the tip
lobule and alar lobules, smoothing the transition. (c) The alar rim grafts create a more triangular shape to
the nasal base. (From Toriumi DM, Checcone MA. Facial Plast Surg Clin N Am. 2009;17:55–90.)

passes from the medial side of the dome through

to the lateral side and then back to the medial side
of the dome. As the suture is cinched down, the
dome will narrow. By placing two separate dome
sutures, the normal divergence of the intermedi-
ate crura can be preserved (the senior author uses
a 5-0  PDS in most cases). Once the two dome
sutures are in position, an interdomal suture
should be placed to set the distance between the
domes (Figure 21.13).
Once the domes are narrowed, additional
refinement of the nasal tip can be achieved with
grafting. Placement of a horizontally oriented
tip graft over the domes is an effective means of
creating further narrowing and definition while
preserving the normal bidomal highlight of the
nasal tip. For example, the soft cartilage obtained
from a cephalic trim can be gently crushed
and sutured to the domes with 6-0 Monocryl®
(Ethicon, Somerville, NJ) sutures (Figure  21.14).
Figure 21.14  A horizontally oriented tip graft is
In patients with thick skin, tip shield grafts can be
placed. This has a favorable affect on shadowing
used (among thinner-skinned patients, the outline and contours, including creating a shadow in the
of the shield graft is often visible). These grafts are supratip area that continues into the supra-alar
sutured to the caudal margin of the intermediate regions and a subtle supratip break on oblique
crura with 6-0 Monocryl sutures. and lateral views.
In general, greater attention to camouflage of
subtle asymmetries needs to be paid to patients
with thinner skin, among whom contour irregular- may be used to camouflage some of these asymme-
ities are more likely to become apparent with time tries. Perichondrium may also be harvested from
as the skin-soft tissue envelope shrinks onto the the postauricular region.
nasal framework. If costal cartilage was harvested There are a multitude of other nasal tip tech-
for reconstructive maneuvers, the perichondrium niques that are effective and have withstood the

test of time. A complete review of these tip tech-
niques is beyond the scope of this chapter. Good
outcomes in rhinoplasty can be achieved using a
multitude of techniques.
Lateral nasal wall and alar cartilages may be
manipulated by repositioning and grafting tech-
niques, thereby altering the shape and strength
of the nasal tip. LCSGs, with or without repo-
sitioning the lateral crura into more caudally
placed pockets, is an advanced concept in rhino-
plasty. First, the lateral crus is sharply dissected
from the vestibular mucosa after hydrodissec-
tion with local anesthetic. The LCSGs are subse-
quently sutured to the undersurface of the lateral
crura using 5-0  PDS sutures. This adds signifi-
cant strength to the alar cartilages, flattens them
favorably, and assists in prevention of lateral nasal
wall collapse. If caudal repositioning of the lat-
eral crura is required to create more favorable tip
contouring and to create more nostril symmetry,
a new pocket for the lateral crura is dissected
caudally using Converse scissors. It is important
that this pocket be caudal to the alar groove to
prevent the lateral crura from becoming visible
(Figure 21.15).
Closure
Attention to detail in closure of the columel-
lar incision is paramount to avoid unsightly
scarring. The corners of the inverted V incision
Figure 21.15  The plan to caudally reposition
the lower lateral cartilages is depicted. This
will reduce supratip bulk, as well as improve
shadowing and contour of the nasal dome and
sidewalls.
External rhinoplasty: Intraoperative details  197
should be carefully aligned and closed with slight
skin edge eversion. The senior author places an
interrupted 6-0 Monocryl subcutaneous suture
in the midline, followed by alternating 7-0 nylon
vertical mattress and 6-0 simple interrupted fast-
absorbing gut sutures. The marginal incisions are
closed with simple interrupted 5-0 chromic gut
sutures.
After columellar and marginal incision closure,
attention may be turned to alar base reductions,
if necessary. Excess alar flare may be corrected
with lateral alar base reduction 1–2 mm above the
alar-facial groove without altering the nostril size
(Figure 21.16). Excess base insertion width (larger
nostrils with excess flare) may be corrected with
medial alar base reduction (Figure 21.17).
The nasal septal mucoperichondrial incision
should be closed with 5-0 interrupted chromic
sutures. Nasal septal flaps should be reapposed
using a 4-0 running plain gut suture on a straight
septal needle, making a U-shaped suture line from
anterior to posterior. Avoiding a circular closure
is important so inadvertent strangulation of the
blood supply to the mucoperichondrium does not
occur.
Lateral base reduction
Figure 21.16  Alar base reduction. Excess alar
flare or base insertion width can be corrected
with lateral or medial alar base reductions,
respectively. A lateral alar base reduction is
performed using a #11 scalpel to excise soft
tissue 1 to 2 mm above the alar-facial groove
to allow for better skin eversion on closure and
hence more inconspicuous scarring. The lateral
base excision reduces alar flare without altering
the nostril size.
198 Rhinoplasty
Medial base reduction
Figure 21.17  A medial alar base excision in
the nasal sill with a #11 scalpel blade is per-
formed if both nostril size and alar flare require
­reduction. The skin excision should be made with
a ­favorable 10° to 15° bevel to allow for better
skin eversion.
Nasal packing/septal splints
Finally, one should consider the need for postop-
erative nasal packing. If there is minimal distance
between the nasal septum and the inferior tur-
binate, a small amount of nasal packing (strip of
Telfa® covered with bacitracin ointment) is placed
overnight, mostly for the purpose of preventing
any friction between the mucosal surfaces that
may result in postoperative synechiae formation.
If the distance between the nasal septum and the
inferior turbinate is adequate, there is less chance
of this complication occurring, and packing is not
necessary. In cases of septal perforation repair
or inferior turbinate reductions, radiopaque sep-
tal splints (Xomed bivalve splints) are sutured
in place with a 5-0 nylon mattress suture. Septal
splints are removed 2 to 4 weeks postoperatively
in the clinic.
Nasal sidewall splints
In cases of LCSGs with repositioning, sidewall
splints are fashioned from radiopaque bivalve splints
and placed on the external and internal side of the
nasal alae. They are loosely sutured in place using a
5-0 nylon suture with removal on postoperative day
(POD) 7 when the cast comes off. These sidewall
splints prevent the LCSGs from becoming dislodged
out of their pockets and also prevent excessive side-
wall thickness.
Dorsal splint
At the conclusion of the operation, a small strip
of Telfa is placed over the dorsum with subse-
quent Steri-Strip™ (3M, St. Paul, MN) placement.
An appropriate size thermoplastic moldable splint
is then placed over the nasal dorsum and sidewalls.
POSTOPERATIVE DETAILS
Postoperatively, the patients are placed on a topi-
cal and systemic antibiotic regimen. Revision
cases also perform topical nasal soaks with a self-­
prepared antibiotic solution consisting of 0.9%
normal saline and antibiotic. These soaks help pre-
vent colonization of bacteria at the nasal vestibule
and prevent entry from pathogens through the
marginal incision sites. All patients, both primary
and revision cases, are asked to clean their inci-
sions gently using hydrogen peroxide with applica-
tion of bacitracin ointment.
Patients are seen in clinic on POD 1 for local
wound care and packing removal and on POD 7
for suture and cast removal. Septal splints, if used,
are removed on POD 14 or later depending on the
reason for placement. Postoperative clinic follow-
up is extremely important. Not only does the close
follow-up allow the surgeon to maximize favor-
able outcomes through instituting home compres-
sion exercises, performing in-office needle shaves,
or injecting triamcinolone acetonide in cases of
asymmetric or excess soft tissue edema, but also
it gives the surgeon an opportunity to learn and
perfect his or her nasal analytical skills, decision
making, and surgical technique.
CPT CODING
30400 Rhinoplasty, primary; lateral and alar
­cartilages and/or elevation of nasal tip
30410 Rhinoplasty, primary; complete, external
parts including bony pyramid, lateral and alar
cartilages, and/or elevation of nasal tip
30420 Rhinoplasty, primary; including major
septal repair
30430 Rhinoplasty, secondary; minor revision
(small amount of nasal tip work)
30435 Rhinoplasty, secondary; intermediate
­revision (bony work with osteotomies)
30450 Rhinoplasty, secondary; major revision
(nasal tip work and osteotomies)

REFERENCES
1. Tardy ME, Thomas JR. Rhinoplasty. In:
Flint PW, Haughey BH, Lund VJ, et al., eds.
Cummings Otolaryngology: Head and Neck
Surgery. 5th ed. Philadelphia, PA: Mosby
Elsevier; 2010:508–544.
2. Toriumi DM, Checcone MA. New concepts
in nasal tip contouring. Facial Plast Surg Clin
N Am. 2009;17:55–90.
3. Tardy ME. Rhinoplasty: The Art and the
Science. Philadelphia, PA: Saunders; 1996.
4. Toriumi DM. New concepts in nasal
tip contouring. Arch Facial Plast Surg.
2006;8(3):156–185.
5. Boahene KD, Hilger PA. Alar rim ­grafting
in rhinoplasty: indications, technique,
and outcomes. Arch Facial Plast Surg.
2009;11(5):285–289.
References 199
6. Toriumi DM, Brennan TE. Management
of the middle nasal vault. Op Tech Plast
Reconstr Surg. 1995; 2(i):16–30.
7. Angelos PC, Been MJ, Toriumi DM.
Journal club: contemporary review
of rhinoplasty. Arch Facial Plast Surg.
2012;14(4):238–247.
8. Boenisch M, Nolst Trenité GJ. Reconstruction
of the nasal septum using polydioxanone
plate. Arch Facial Plast Surg. 2010;12(1):4–10.
9. Sheen JH. Rhinoplasty: personal ­evolution
and milestones. Plast Reconstr Surg.
2000;105(5):1820–1852; discussion 1853.
10. Constantian MB. The boxy nasal tip, the ball
tip, and alar cartilage malposition: variations
on a theme—a study in 200 consecutive
primary and secondary rhinoplasty patients.
Plast Reconstr Surg. 2005;116(1):268–281.
 22
Correction of prominent ear

ALEJANDRA GARCIA DE MITCHELL AND H. STEVE BYRD

Introduction 201 Notes 205

Preoperative evaluation and documentation 203 CPT coding 205
Intraoperative details 203 References 205
Postoperative details 205 Acknowledgment 206

INDICATION

Desire to correct prominent ears to achieve symmetric and normal ear aesthetics.

Table 22.1  Special equipment

Clear adhesive drapes (2) 15 in L ×15 in with circular aperture
Clear adhesive drape 10 in × 10 in
Bonnie’s blue (or methylene blue) in 1-mL syringe with 27-gauge, 1½-in needle
Dressing:
Petroleum gauze
bacitracin ointment
large sterile cotton pad
Kerlix roll gauze
Flexinet

INTRODUCTION (i.e., microtia), where tissue is deficient and surgi-

Congenital ear deformities are present in up to
29% of infants, and only one-third of these self-
correct. There is a window of opportunity to cor-
rect the remaining deformities with ear-molding
therapy in the newborn period. The distinction
needs to be made between ear deformation, which
is amenable to molding, and ear malformation
cal reconstruction is necessary. Ear molding has
been shown to be highly successful if initiated
within the first week of life. The premise is that cir-
culating maternal estrogen levels are high at birth
and the cartilage is most malleable.1 After 3 weeks
of age, molding therapy is successful in fewer than
50% of cases.2 Table 22.1 indicates equipment
needed for the procedure.

201
202  Correction of prominent ear

The most common ear deformity is the
­ rominent/cup ear deformity (45%). This may be
p contour throughout the entire curve.
unilateral or bilateral. Although physiologic effects
are minimal, there may be significant psycho-
logical distress and emotional trauma associated
with the condition. When the older child pres-
ents for correction, surgical repair is considered
(Figure 22.1a–d).
The goals of surgical otoplasty are as follows3:
3. The helix and antihelix should have a smooth
4. The helix-to-mastoid distance should fall
within the normal range: 10- to 12-mm upper
third, 16-mm middle third, 20- to 22-mm
lower third.
5. The conchoscaphal angle should be 90°.
6. There should be symmetry within 3 mm
between the two ears.

1. Correction of all upper third ear protrusion. The ear attains nearly 85% of its adult size by age
2. The helix of both ears should be visible 3 years. Maximum width is reached by approxi-
beyond the antihelix from the anteroposterior mately age 6 in girls and 7 in boys.4 Thus, 5–7 years
(AP) view. is the optimal timing for surgical correction.

(a)   (b)

(c)   (d)

Figure 22.1  Prominent ear: (a) preoperative AP view of patient with bilateral prominent ears desiring
correction; (b) postoperative AP view; (c) preoperative lateral view; (d) postoperative lateral view.

As the person matures, the ear cartilage becomes
more ­calcified and stiffer, requiring adaptation
of techniques (cartilage breaking rather than
­molding).
PREOPERATIVE EVALUATION
AND DOCUMENTATION
1. Determine symmetry.
2. Determine the extent of antihelical folding
and conchoscaphal angle.
3. Note the depth of the conchal bowl.
4. Evaluate the lobule for prominence and
­deformity, if present.
5. Determine the distance between the helical
rim and the mastoid plane at the superior,
middle, and lower thirds.
6. Note the flexibility and spring of the auricular
cartilage.
INTRAOPERATIVE DETAILS
1. Place a head doughnut and shoulder roll with
the patient in the supine position. All hair is
tied back to fully visualize both ears. Prep with
Betadine® (Purdue Products, Stamford, CT)
surgical prep. Secure a head drape with staples
and cover any remaining exposed hair with
a 10 × 10 sterile plastic adhesive drape or use
the one with a circular aperture. Make sure
both ears are visible on AP view. If both ears
are prominent, start with the more severe of
the two.
2. Mark the position of antihelix to be re-created
with Bonnie’s blue ink or methylene blue in a
Figure 22.2  Markings: location of antihelix.
Intraoperative details  203
1-mL syringe with a 27-gauge, 1½-inch needle.
Insert the needle from the anterior surface
through the posterior skin, squeeze a drop of
dye, and pull back through to mark all layers
through and through. This should result in
a row of paired points along either border of
the antihelix (Figure 22.2).
3. Mark the conchal height: Use the same tech-
nique as in step 2 to mark through all tissue
layers. Mark 7 mm of conchal height (9 mm
for an adult) at midchoncha and extend
markings all the way around the conchal ring
superiorly and inferiorly.
4. Mark the postauricular incision at the level of
the antihelix (Figure 22.3).
5. Inject 0.5% xylocaine with 1:200,000 epi-
nephrine anteriorly to hydrodissect along
the ­subperichondrial plane.
6. Make the postauricular incision with a
#15 blade. Dissect the skin envelope with
tenotomy scissors toward the helical rim until
the methylene blue dots demarcating the
junction between the helical rim and scapha
are encountered. Carefully cut through the
cartilage along this row of dots, allowing
exposure of the anterior surface of the scapha.
A very fine remnant of cartilage will remain
attached to the helical rim. As dissection is
directed along the anterior surface of the sca-
pha, the helical rim and anterior skin will be
lifted. Dissection is in the supraperichondrial
plane posteriorly and in the subperichondrial
plane anteriorly until exposing the antihelix
markings. A fine fibrous layer on the anterior
surface should remain (Figure 22.4).
Figure 22.3  Markings: post-auricular incision.
204  Correction of prominent ear
Figure 22.4  Cartilage exposure: dissection of
skin envelope.
Figure 22.5  Cartilage scoring of the anterior sur-
face marked to facilitate folding of the antihelix.
7. Gently score the anterior surface of the anti-
helix with a #15 blade to allow the cartilage to
bend posteriorly. Scoring should be performed
in the direction parallel to the antihelix
(Figure 22.5).
8. Place Mustardé sutures to re-create the anti-
helix. These should be a permanent material
such as 4-0 clear nylon on a P-3 needle. The
Mustardé suture is a horizontal control suture
that is placed from the posterior surface and
incorporates the full thickness of the car-
tilage and anterior fibrous surface. At least
three stitches should be placed. Check each
Figure 22.6  Mustardé sutures: re-creating
the antihelical fold.
Figure 22.7  Conchal ring release.
one by folding the cartilage manually and
tie all at the end. Redrape the skin envelope
(Figure 22.6).
9. If there is conchal height excess (more than
7 mm in a child or 9 mm in an adult), cut
through the concha along the mark and
continue the cut all the way around the
conchal ring superiorly and inferiorly. The cut
should actually break through the cartilage
between the tragus and lobule inferiorly and
break through beneath the superior crus helix
superiorly. This helps eliminate the tendency
toward “telephoning” (Figure 22.7).
1 0. Remove a small (3-mm) crescent of concha
cymba and then suture plicate the concha
cymba back to the mastoid fascia (à la Furnas).
The vertical wall of the concha is then
sutured back to the mastoid fascia. Do not
approximate it to the concha cymba but rather
let it stretch the soft tissue in the ­concha
­posteriorly. This will eliminate the need for
anterior skin excision (Figure 22.8).

Figure 22.8  Conchal reconstruction: decrease conchal height and conchal-mastoid angle.
11. Lobule prominence: If this deformity is
identified, extend the skin excision in a fishtail
pattern inferiorly.5 When closing, this will
bring in the lobule.
12. Perform a final comparison between the
two ears for symmetry and desired final
­correction. Close the postauricular skin
­incision with running 4-0 chromic. If there is
­significant skin excess, it can be resected prior
to closing.
13. Dressing: Antibiotic ointment and xeroform/
petroleum gauze are placed generously onto
the scapha, conchal bowl, and p ­ ostauricular
sulcus to maintain gentle pressure on all
surfaces. Apply large cotton padding on top of
this, followed by Kerlix™ (Covidien, Dublin,
Ireland) roll gauze wrapped around both ears
and head. Secure the entire dressing with
Flexinet® (Derma Sciences, Princeton, NJ).
POSTOPERATIVE DETAILS
Patients can be discharged home on the same
day with prophylactic antibiotics for 7 days. They
should be given instructions to keep the dressing
in place and intact. Discomfort may be expected,
but severe pain should be evaluated promptly to
rule out a hematoma. Otherwise, the dressing can
be removed in the office in 5 days and replaced
with a lighter but protective daily dressing for
the next 3 weeks. A sports band or headband is
recommended for a total of 6 weeks, as well as
avoidance of activities that could cause trauma
to the area.
NOTES
Perioperative complications such as hematoma
must be addressed promptly with drainage to avoid
References 205
permanent cartilage damage and distortion. Other
complications include asymmetry, telephone ear
deformity, and recurrence. If one adheres to care-
ful preoperative evaluation, meticulous intraop-
erative technique, and postoperative management,
these can be minimized.
The traditional Furnas technique for conchal
setback does not include cartilage incision or
resection. In the senior author’s experience, the
technique described in this chapter allows for
release of the conchal ring forces, decreasing the
tendency for telephone deformity or ­recurrence.
In  addition, a combination of light anterior scor-
ing with ­posterior sutures has been more accurate
in achieving the desired bend in the antihelix,
the desired projection of the helical rim from the
mastoid, less relapse and over-projection, and far
less over-correction with a rim posterior to the
antihelix.
CPT CODING
69300 Otoplasty, protruding ear, with or without
size reduction
REFERENCES
1. Kenny FM, Angsusingha K, Stinson D,
Hotchkiss J. Unconjugated estrogens
in the perinatal period. Pediatr Res.
1973;7:826–831.
2. Byrd HS, Langevin CJ, Ghidoni LA. Ear
molding in newborn infants with auricu-
lar deformities. Plast Reconst Surg.
2010;126(4):1191–1200.
3. McDowell AJ. Goals in otoplasty for
protruding ears. Plast Reconst Surg.
1968;41:17.
206  Correction of prominent ear

4. Adamson JE, Horton CE, and Crawford HH. ACKNOWLEDGMENT

The growth pattern of the external ear.
Plast Reconst Surg. 1965;36:466. We are grateful for the artistic contribution of
5. Wood-Smith D. Otoplasty. In: Rees T, ed. Kriya Gishen.
Aesthetic Plastic Surgery. Philadelphia,
PA: Saunders; 1980:833.
 23
Breast augmentation

ELLIOT M. HIRSCH AND JOHN Y.S. KIM

Introduction 207 Notes 210

Preoperative markings 207 CPT coding 211
Intraoperative details 208 Acknowledgment 211
Postoperative care 210 References 211

INDICATION

Desire for aesthetic improvement in breast size, shape, or symmetry

Table 23.1  Special equipment

Breast implant
Antibiotic irrigation (composition)
Sterile injectable saline
Separate IV tubing setup for injectable saline
3-way stopcock
60-mL syringe

INTRODUCTION in detail in this chapter. Table 23.1 lists the equip-

Breast augmentation is one of the most commonly
performed cosmetic surgery procedures in the
United States. These procedures are typically well
tolerated by patients and offer them the oppor-
tunity to dramatically improve the appearance
of their breasts. There are many different options
regarding implant type, including saline, silicone,
smooth, and textured implants. Some implants
are round; others are shaped anatomically. Breast
implants may be inserted through inframammary
fold incisions, periareolar incisions, or axillary
incisions or even through the umbilicus; we prefer
the inframammary fold approach and describe it
ment for the procedure.
PREOPERATIVE MARKINGS
(FIGURES 23.1 AND 23.2)
1. Midline from sternal notch to xiphoid.
2. Inframammary fold.
3. Sternal notch to nipple.
4. Upper breast border.
5. If the inframammary approach is desired,
mark the incision below the nipple in
the inframammary fold. The marking
should be placed slightly below the infra-
mammary fold as it tends to ride up after

207
208  Breast augmentation
Figure 23.1  Preoperative markings, anterior view.
All three approaches are marked for the pur-
poses of demonstration: (a) inframammary fold
incision; (b) periareolar incision.
Figure 23.2  Preoperative markings, oblique
view. All three approaches are marked for the
purposes of demonstration: (a) inframammary
fold incision; (b) periareolar incision; (c) axillary
incision.
the implant is placed. If the periareolar
approach is desired, mark the inferior border
of the areola. If the axillary approach is uti-
lized, mark the incision slightly posterior to
the anterior axillary line so that the scar will
be hidden by the anterior axillary fold. In all
three approaches, the length of the incision is
determined by the size of the implant. Silicone
implants in general require larger i­ ncisions
than saline implants.
INTRAOPERATIVE DETAILS
1. Position the patient supine on the operating
table with arms extended to 75°–90°. Pay spe-
cial attention to shoulder position; it should be
symmetric, with both shoulders at the same
height.
2. Prep and drape the patient in the standard
fashion.
3. If using the inframammary approach, make
an incision in the previously marked line in
the inframammary fold using a #15 blade, and
carry the incision through the dermis into the
subcutaneous tissue.
4. Place a double-prong skin hook into the inci-
sion and, using the electrocautery held at a 45°
angle to the skin, dissect down to the pectora-
lis major away from the inframammary fold.
5. Remove the double-prong skin hook and place
an Army-Navy retractor into the incision.
Continue dissection to the surface of the
­pectoralis major.
6. Elevate breast parenchyma off the surface of
the pectoralis major muscle up to the level
of the nipple (Figure 23.3). Note: When using
the periareolar approach, after incising the
skin, dissection may proceed through the
parenchyma to the surface of the pectoralis
or through the subcutaneous tissues in the
lower pole of the breast to the pectoralis.
After the pectoralis is reached, the remain-
ing steps of the procedure, including step 6,
are the same as for the inframammary
approach.
7. Using electrocautery, cut through the inferior
attachments of the pectoralis major muscle to
reach the loose areolar plane beneath.
8. Place a narrow Deaver retractor into the
incision beneath the pectoralis major muscle
and release the inferior attachments of the
pectoralis muscle.
9. Continue dissection medially beneath the
pectoralis muscle until the medial insertions
of the muscle are reached (Figure 23.4).
10. Continue dissection superiorly beneath the
pectoralis muscle until an adequate sized
pocket has been created to accommodate the
implant
11. Continue dissection laterally until the first
layer only of the lateral fascia is divided.
12. Use bipolar cautery to ensure meticulous
hemostasis, then irrigate copiously with anti-
biotic irrigation
13. The circulating nurse should then open the
implant package, and the scrub nurse should
pour antibiotic irrigation over the implant.
 Intraoperative details  209

Figure 23.3  Pectoralis muscle cleared of overlying parenchyma. Arrow points to anterior surface of
pectoralis muscle.

Figure 23.4  Inferior border of the pectoralis muscle after division. Arrow points to cut edge of
­pectoralis muscle.

14. The surgical team should change gloves before
handling the implant, and gloves without
powder should be utilized.
15. If the implant is a saline implant, the tubing
should be connected to the valve, and 20 mL
of sterile saline should be injected into the
implant.
16. The implant should then be evacuated of air,
as well as the previously inserted saline.
17. Three Army-Navy retractors are then placed
into the breast, and retraction should occur in
three different vectors of force to spread the
incision.
18. A saline implant may be rolled up and
inserted into the breast; a silicone implant
should be grasped firmly with one hand and
rotated into the incision while pushing with
the other hand.
19. After insertion, the saline implant should be
filled with injectable saline to the determined
fill volume and the tubing removed from the
implant.
20. The head of the bed should be elevated, and
the breasts may be observed. Often, it is
necessary to apply digital pressure to the
lateral aspect of the implant pocket to
210  Breast augmentation
complete dissection. It is important to
­perform this after the implant has been placed
rather than at the beginning of the procedure
to avoid overdissection.
21. The incision is then closed in layers:
3-0 Vicryl® (Ethicon, Somerville, NJ)
in the breast parenchyma, 4-0 Vicryl
in the ­dermis, and 4-0 Monocryl®
(Ethicon) in a running subcuticular
stitch. The ­i ncision may be dressed with
a Steri-Strip ™ (3M, St. Paul, MN) or
Dermabond® (Ethicon).
2 2. A surgical brassiere or a 6-inch Ace™ (3M)
wrap is placed on the patient’s chest.
POSTOPERATIVE CARE
Patients typically return home after surgery.  Post­
operative antibiotics are not routinely used. Patients
may be instructed to avoid strenuous activity or
Figure 23.5  Preoperative picture of breast
­augmentation patient (frontal view).
Figure 23.7  Preoperative picture of breast aug-
mentation patient (oblique view).
heavy lifting for 2–4 weeks following surgery.
Patients are encouraged to begin manual breast
massage as soon as tolerated. See Figures 23.5 to
23.12 for preoperative and postoperative breast
­augmentation patient photos.
NOTES
Meticulous hemostasis is critical to o ­ptimizing
outcomes in breast augmentation procedures.
Subclinical bleeding may lead to increased inflam-
mation and could contribute to capsular contrac-
ture formation. The implant should not be inserted
until absolute hemostasis has been achieved.
In addition, it is critical to adhere to principles of
operative sterility. The implant should not be set
down on the operating table or on the patient;
it  should be picked up from the package and
directly inserted into the breast as in a “no-touch”
technique to minimize bacterial contamination.
Figure 23.6  Postoperative picture of breast aug-
mentation patient (frontal view).
Figure 23.8  Postoperative picture of breast aug-
mentation patient (oblique view).

Figure 23.9  Preoperative picture of breast
­augmentation patient (frontal view).
Figure 23.11  Preoperative picture of breast
­augmentation patient (oblique view).
In general, breast augmentation procedures
are well tolerated by patients.1 Complications are
relatively rare but may include hematoma, infec-
tion, poor scarring, asymmetry, implant rotation
(specific to anatomically shaped implants), implant
deflation (more common in saline breast implants),
implant rippling, and capsular contracture, which
is the most common complication associated with
breast augmentation.2,3 The incidence of capsular
contracture is highly variable depending on type of
implant and surgical technique but has been esti-
mated to occur at a rate from 10–30% at 5 years.4,5
Treatment of capsular contracture may include
capsulotomy, capsulectomy, implant plane change,
and revision with acellular dermis.6 Finally, in
recent years, the long-term use of silicone breast
implants has rarely been associated with the devel-
opment of anaplastic large cell lymphoma. This
phenomenon is poorly understood but seems to
be localized to the implant capsule and should be
treated by total capsulectomy.7–9
References 211
Figure 23.10  Postoperative picture of breast
­augmentation patient (frontal view).
Figure 23.12  Postoperative picture of breast
­augmentation patient (oblique view).
CPT CODING
19325 Breast augmentation
ACKNOWLEDGMENT
We would like to acknowledge Ms. Jessica Gaido
for her assistance in the preparation of this chapter.
REFERENCES
1. Handel N, Cordray T, Gutierrez J, Jensen J.
A long-term study of outcomes, com-
plications, and patient satisfaction with
breast implants. Plast Reconstr Surg.
2006;117:757–767.
2. Adams WP, Mallucci P. Breast augmenta-
tion. Plast Reconstr Surg. 2012;130:597e.
3. Alpert BS, Lalonde DH. MOC-PS CME
article: breast augmentation. Plast Reconstr
Surg. 2008;121:1.
212  Breast augmentation
4. Mentor Corporation. Saline filled breast
implant surgery. Making an informed
decision: 102864-001 [patient brochure].
Santa Barbara, CA: Mentor Corporation;
2004 [updated 2009]. http://www.fda.gov/­
downloads/medicaldevices/productsand-
medicalprocedures/implantsandprosthetics/
breastimplants/ucm064453.pdf.
5. US Food and Drug Administration.
2003 and 2005 breast implant PMA
information. http://www.fda.gov/cdrh/
breastimplants.
6. Basu CB, Jeffers L. The role of acellular
dermal matrices in capsular contracture:
a review of the evidence. Plast Reconstr
Surg. 2012;130(5 Suppl 2):118S–124S.
7. Brody GS. Brief recommendations for
dealing with a new case of anaplastic large
T-cell lymphoma. Plast Reconstr Surg.
2012;129(5):871e–872e.
8. Lazzeri D, Agostini T, Pantaloni M,
D’Aniello C. Further information on anaplas-
tic large cell lymphoma and breast implants.
Plast Reconstr Surg. 2011;128(3):813–815.
9. Jewell M, Spear SL, Largent J, et al.
Anaplastic large T-cell lymphoma and
breast implants: a review of the literature.
Plast Reconstr Surg. 2011;128(3):651–661.
 24
Mastopexy

LEILA HARHAUS AND MING-HUEI CHENG

Introduction 213 Vertical scar techniques 217

Preoperative markings 214
Periareolar techniques 214
Vertical techniques 214
Inverted T techniques 214
Intraoperative details 215
Periareolar technique 215
Inverted T technique 218
Suspension technique (Graf-Biggs technique) 219
Postoperative details 219
Notes 220
CPT coding 220
References 220

INDICATIONS

Breast ptosis due to:

1. Changes in body weight 4. Congenital deformities

2. Pregnancy and breast-feeding 5. Soft tissue quality
3. Hormonal changes

Table 24.1  Special equipment

Different areolar markers of standard sizes (38–48 mm, depending on cultural
differences)
Skin hooks
Redon-Drains or Jackson-Pratt drains
Stable, braided sutures for subcutaneous stabilization
Nonabsorbable monofilament suture for purse-string technique
Resorbable, monofilament suture material for skin suture

INTRODUCTION deformity and  sunken position of the breast

Ptosis of the breast is the result of parenchy-
mal volume decrease in combination with a
reduced ability of the skin envelope and the
supporting structures to retract. The resulting
on the chest  wall  can be classified according to
Regnault1:
Grade I: nipple lies still at the level of inframam-
mary fold (IMF)

213
214 Mastopexy
Grade II: nipple lies below the IMF but above the
most dependent part of the breast
Grade III: nipple is at the most dependent part of
the breast parenchyma, much below the IMF
Pseudoptosis is characterized by an increased
­areola-IMF distance, where the majority of the
breast tissue has descended below the IMF, but the
areola still lies above it.
To find the best technique suitable for each
individual, it is important to assess the ptosis
degree, the breast volume, the nipple position,
the size of the areola, as well as redundancy of
the skin envelope. From the surgical or techni-
cal side, consideration must be given to the skin
incision and subsequent scar camouflage, the
positioning of the pedicle of the nipple-areola
complex, the positioning of the new IMF, and
finally the projection, especially in the superior
and medial parts.
The history of mastopexy procedures has
evolved parallel with procedures of reduction
mammoplasty, and all developed techniques were
designed to treat ptosis of the breast. The modern
techniques aim to produce shorter scars, achieve
more parenchymal support, and allow greater lon-
gevity.2 The large variety of different techniques
can be divided into three groups, which are all
named by their incisions respectively and their
resulting scars: the periareolar techniques, the ver-
tical techniques, and the inverted T techniques.
The surgical goals of mastopexy procedures
are (1) a reliable transposition of the areola, (2) a
re-creation of a pleasing shape of the breast, and
(3) production of short scars, wherever possible.
Table 24.1 indicates the special equipment needed.
PREOPERATIVE MARKINGS
Periareolar techniques
1. Midline from sternal notch to umbilicus.
2. Bilateral IMF.
3. Line from sternal notch to bilateral areola and
definition of future nipple position, which
should range from 19 to 21 cm.
4. Mark the incision pattern around the nipple
site, which can be planned as a concentric, an
eccentric, or a crescent incision.3–8 The eccen-
tric pattern is preferred currently to achieve
maximal elevation of the areola9 (Figure 24.1).
Figure 24.1  A 43-year-old patient with grade
I ptosis of the left breast (s/p carcinoma of
the right breast and ablation). Marking of the
midline, the upper breast margin, the IMF, and
the periareolar incision for mastopexy. The new
nipple-IMF distance is planned to be 5 cm.
Vertical techniques
1. Midline from sternal notch to umbilicus.
2. Bilateral IMF.
3. Create an oval circle approximately 2 cm above
the eventual nipple site, gently curving around
each side.
4. Mid-clavicular bilateral line from clavicle to
upper abdomen, then move the breast with the
hand to both sides to mark the medial and lateral
incisions to approximately 3.0–4.0 cm above the
IMF, where both lines join together (Figure 24.2).
Inverted T techniques
1. Midline from sternal notch to umbilicus.
2. Bilateral IMFs with medial and lateral end
points, as well as marking the middle point.
3. Distance from sternal notch to new nipple
position; consider adding approximately 10%
of this length due to the pendulum rule10 to
avoid a higher location than planned.
4. Around this point, a Wise keyhole pattern is
drawn with an oval (usually around 5.0 cm)
around the areola. The angle of the vertical
lines of the inverted T is determined by shift-
ing the breast from medial to lateral and defin-
ing it on the mid-clavicular line. The length
of this future areola-IMF distance should be
5.0–6.0 cm.

Figure 24.2  A 47-year-old patient after left
breast carcinoma and reconstruction with a deep
inferior epigastric perforator (DIEP) flap. The
right breast shows grade II ptosis. A vertical scar
mastopexy is planned; the markings show the
midline, the upper breast margin, and the inci-
sion pattern.
5. The endpoints of the vertical lines are con-
nected to the lateral and medial end points of
the IMFs (Figure 24.3).
INTRAOPERATIVE DETAILS
Periareolar technique
The periareolar approach (so-called Benelli tech-
nique11) is the favorable technique for cases with
mild ptosis of the breast, which is limited to grade
I ptosis.3,5,6,9 It results in the shortest possible scar
pattern, which can be placed at the border of the
pigmented areola skin and provide a pleasing scar
camouflage. The sensation and blood supply of the
areola are well preserved by preserving the sub-
dermal plexus during deepithelialization of the
periareolar skin. Even though there are many vari-
ations described, this technique is still named after
Benelli and his 1990 “round block” technique.11
1. During positioning of the patient in supine
position, look for symmetric position of the
shoulders and arms as well as straight align-
ment of the pelvis.
2. After skin disinfection with a transparent
solution, the draping should be precisely
symmetric. Proximally the acromions, later-
ally the anterior axial folds, and caudally the
Intraoperative details  215
Figure 24.3  A 22-year-old patient with asymme-
try of the breasts. The right breast shows grade
II ptosis; the left breast shows grade III ptosis.
The marking for inverted T scar mastopexy for
Hidalgo technique with a central mound can be
seen.
umbilicus should be exposed for orientation
purposes.
3. Redraw the marking lines.
4. To achieve maximal tension of the skin and to
reduce bleeding, the breast can be secured at
its base with a tourniquet. The authors favor
a simple sterile glove that has good elastic-
ity, can be tied easily, and holds its position
sufficiently.
5. With the selected areolar marker (cookie cut-
ter), the areola is marked.
6. The skin incision is made at this marking and
the periareolar oval marking, then deepitheli-
azation of this area is performed.
7. Undermine the breast skin at the lower pole
while leaving the areola on a superiorly based
dermoparenchymal pedicle. Remove the
tourniquet.
8. The glandular tissue beneath the areola is
then split vertically, and two superiorly based
winglike flaps are created. Careful control of
bleeding is necessary.
9. Each glandular flap is then sutured with
nonabsorbable material to the periosteum of
the fourth or fifth rib opposite the breast. This
creates a crisscross sling of the parenchyma,
decreasing the breast base and increasing
the projection as a kind of internal brassiere
(Figure 24.4).
216 Mastopexy

Figure 24.4  Glandular repositioning technique for periareoloar mastopexy.


1 0. Implant of a Jackson-Pratt drain on each side.
11. A nonabsorbable purse-string suture is placed
intradermally around the deepithelialized
oval area. The purse string is tightened until
the desired diameter of the future areola is
achieved, usually 30–38 mm.
12. Use absorbable monofilament suture for the
final skin closure. The wrinkling resulting
from the redundant skin of the outer skin
circle has to be adjusted; it usually resolves
within a few months.12,13
13. The skin is disinfected again. Steri-Strip™
(3M, St. Paul, MN) tapes are placed to
secure the sutures and to take some tension
from the skin. Dry gauze, tape, and special
dressing, which allows for continuous support
of the nipple-areola complex, are also placed.
ADVANTAGES
●● Short scar
●● Scar camouflaged at border of areola
DISADVANTAGES
●● Scar and areolar widening occur frequently.
●● Breast projection can be flattened.
●● Purse-string closure results in skin pleating,
which takes several months to resolve.
Vertical scar techniques
Vertical scar techniques (named after Lassus and
Lejour13,14) can be used for patients with more
severe ptosis; best results are achieved for grade
II ptosis cases. The techniques add a vertical or
oblique limb to the periareolar scar. The reduction
mammoplasty techniques of Lassus, Lejour, and
Hammond work in almost the same way for mas-
topexy (Figure 24.5).
Figure 24.5  Vertical scar technique: (left) Lassus, (center) Lejour, and (right) Hammond.
Intraoperative details  217
The vertical component of the incision can be
part of the initial planning and drawing, such as
in the oval-shaped pattern by Lassus or the dome-
shaped incision by Lejour.14–17 Hammond initially
worked over a periareolar incision and then resected
the redundant skin to the lower portion of the are-
ola, where it can be excised in a vertical fashion.12
1. During positioning of the patient in supine
position, ensure symmetric position of the
shoulders and arms as well as straight align-
ment of the pelvis.
2. After skin disinfection with a transparent
solution, the draping should be precisely sym-
metric. Proximally the acromions, laterally the
anterior axial folds, and caudally the umbili-
cus should be exposed for better orientation.
3. Redraw the marking lines.
4. To achieve maximal tension of the skin and to
reduce bleeding, the breast can be secured at
its base with a tourniquet. The authors favor
a simple sterile glove that has good elasticity,
can be tied easily, and holds its position.
5. With the selected areolar marker (cookie cut-
ter), the areola is marked.
6. The skin incision is made at this marking and
the periareolar marking, then deepithelializa-
tion of this area is performed.
7. The extension of undermining of the skin is
performed differently by the various authors.
Lassus limits the undermining to preserve
nipple sensation and perfusion,17 while
Lejour performs extensive skin undermin-
ing of the lower hemispheres to enhance skin
retraction.15
8. The reshaping and redistribution of the
glandular tissue can be achieved using dif-
ferent techniques. Lassus17 uses a superiorly
218 Mastopexy
based inferior flap of the central lower tissue,
which is mobilized and transported through a
retroglandular dissection to a higher position.
It is sutured to the pectoralis fascia to increase
upper pole fullness. In the technique of Lejour,
the same principle is used but without incision
of the inferior flap.14,15
9. Meticulous hemostasis is achieved.
10. After this folding of the breast tissue and
securing the lower pole to the chest wall,
the treatment of the two lateral pillars has
to be performed. They are used to reshape
the breast mound while they are sutured
together. This maneuver increases the projec-
tion of the nipple-areola complex and is the
main component for the longevity of the
breast shape since it consists of less-ptotic
soft tissue from the lateral components of the
breast. In addition, the suspension technique
of Graf and Biggs can be combined18 (please
see below).
11. Insert a Jackson-Pratt drain for each breast.
12. The vertical scar is sutured with a purse-
string-like, nonabsorbable, subcutaneous
suture, which can be used to shorten the
scar and which prevents widening and
dehiscence of the skin. Purse-string suture
around the areola. Skin suture with intra-
dermal, monofilament, absorbable running
suture.
13. The skin is disinfected again. Steri-Strips are
placed to secure the sutures and to take over
some tension. Dry gauze, taping, and special
dressings are placed; these allow continuous
support of the nipple-areola complex.
The vertical component of the scar should not
cross the IMF since scars on the chest wall tend to
hypertrophy and scar unpredictably.14,15,17 In addi-
tion, those scars would be visible below the bras-
siere. Some authors prefer a certain overcorrection
at the time of surgery, which will settle over a
period of 2–3 months to a final position. A detailed
explanation of this process to the patient is indis-
pensable prior to the surgery.
ADVANTAGES
●● A limited vertical scar is achieved without
horizontal IMF incision.
●● Inferior parenchymal closure provides addi-
tional support to limit recurrent ptosis.
DISADVANTAGES
●● The immediate postoperative result often
displays pronounced upper pole fullness that
settles over time.
●● Inferior skin redundancy occasionally does not
retract, requiring horizontal excision later.
Inverted T technique
For patients suffering severe grade III breast pto-
sis with a large amount of redundant skin, the
inverted T technique is the preferred approach.
This technique consists of a periareolar compo-
nent and a vertical component as described above.
In addition, a horizontal component is designed,
which is usually located in the IMF. It is a common
technique in reduction mammoplasty but is use-
ful in the same way for mastopexy. This horizontal
part often results in scarring problems, so various
attempts have been made to shorten this part of the
scar. Strombeck used an oblique instead of a verti-
cal scar, so that the scar is rotated laterally and can
be shortened.19 However, a longer horizontal scar
will allow maximum correction of the ptosis.
1. During positioning of the patient in supine
position, ensure symmetric position of the
shoulders and arms as well as straight align-
ment of the pelvis.
2. After skin disinfection with a transparent
solution, the draping should be precisely
symmetric. Proximally, the acromions, later-
ally the anterior axial folds, and caudally
the umbilicus should be exposed for better
orientation.
3. Redraw the marking lines.
4. To achieve maximal tension of the skin and to
reduce bleeding, the breast can be secured at
its base with a tourniquet. The authors favor
a simple sterile glove that has good elasticity,
can be tied easily, and holds its position.
5. With the selected areolar sizer, the areola is
marked.
6. Skin incision is made at this marking and the
periareolar marking, then deepithelialization
of this area is performed (Figure 24.6).
7. There are several techniques to reshape the
gland. Pitanguy20 uses a lozenge-shaped
glandular resection and a keel resection for
severe ptosis (Arie-Pitanguy). Another way is
to dissect medially and superiorly and then

Figure 24.6  Inverted T technique after incision of
the mastopexy pattern and deepithelialization of
the central part.
dissect the breast from the pectoralis muscle.
This laterally based pedicle is rotated in a
higher and medial direction. The pillars are
positioned one over the other and sutured
together, with the lateral placed on top of
the medial one, as described by Nicolle and
Chir.21 Peixoto excises the inferior pole and
the base of the breast, leaving a cone that is cut
obliquely.22 Furthermore, there are triple-flap
interposition techniques, using a central, a
lateral, and a medial glandular flap to build a
conical shape.23 The distal part of the central
flap is elevated and attached to the pectoralis
fascia and provides the projection. The medial
and lateral flaps are rotated to the hemicla-
vicular line and transposed one over the other.
With this, they build the shape of the lower
hemisphere and define the new IMF while
narrowing the base of the breast. In addi-
tion, some authors use a flip-flap mastopexy
technique that creates a wide, superiorly based
parenchymal flap deep to the McKissock verti-
cal bipedicle design for nipple transposition to
increase the longevity of the procedure.24
8. The authors prefer the following technique to
shape the glandular tissue: In cases with an
inverted T approach, the authors prefer glan-
dular shaping after David Hidalgo and Peixoto
and Lejour for vertical scar technique.
9. Insert a Jackson-Pratt drain for each breast.
10. The subcutaneous tissue is sutured with a
nonabsorbable, subcutaneous suture, which
prevents widening and dehiscence of the skin.
Postoperative details  219
Purse-string suture around the areola.
Skin suture with intradermal, monofilament,
absorbable running suture.
1 1. The skin is disinfected again. Steri-Strips to
secure the sutures and to take over some ten-
sion are placed. Dry gauze, taping, and special
dressings are placed to allow continuous
control of the nipple-areola complex.
ADVANTAGES
●● Surgeons are familiar with this technique
because of widespread use in reduction
techniques.
●● Results are predictable.
DISADVANTAGES
●● Scar burden
●● Recurrent ptosis probable if parenchymal sup-
port not used
Suspension technique (Graf-Biggs
technique)
Graf and Biggs18 in 2002 described a further con-
cept  to enhance the upper pole fullness and to
increase the longevity of the operation result.
An  inferiorly based parenchymatous flap is ele-
vated  and passed under a muscle loop of the
­pectoralis muscle, then secured on the chest wall
with single sutures. This technique can be ­combined
with any vertical or inverted T ­technique. There are
some considerations about placing breast tissue
under the pectoralis major muscle, which may be
an issue for safe diagnosis of breast cancer, but there
is no evidence so far.
POSTOPERATIVE DETAILS
Patients undergoing mastopexy surgery may stay
in inpatient service for 1–2 days or be discharged
the same day. Depending on the technique used,
large wound areas are produced that may show
postoperative oozing or bleeding that need to be
controlled. In addition, there exists a certain risk
of infection. The amount of drainage into the
Jackson-Pratt drains should be observed 2 and
6  hours postoperatively so major bleeding is not
missed. After that, daily control is enough, and the
drains can be removed when less than 10 mL per
day are noticed.
220 Mastopexy
The nipple-areola complex should be monitored
daily to check the perfusion of this part. To sustain
the shaping of the breast, the supporting taping
should be applied for at least 4–6 weeks. Different
products can be used for this issue, but in general,
hypoallergenic and strong tape should be chosen.
A sports brassiere should be worn from the
time point of increasing mobilization of the
patient and can be changed to common brassieres
after 4–6 weeks, when wound healing is com-
pleted and safe.
NOTES
The principles of a reliable areola transposition,
maximal parenchymal tissue support, and mini-
mal scars are even more important in mastopexy,
which has a more aesthetic character than reduc-
tion mammoplasty.
Some patients undergoing a mastopexy proce-
dure also wish for augmentation of the upper pole
fullness, which cannot be achieved with many
mastopexy techniques. Simultaneous use of an
implant may meet these expectations.
However, there are many improvements and
modifications. The periareolar techniques still
obtain the best results in patients with little ptosis,
such as grade I–II, because the preservation and
restoration of an adequate projection remains dif-
ficult with this technique.
Inferior pedicle techniques tend to slightly
lower the IMF, while superior- or medial-­combined
­techniques result in a raised IMF.
CPT CODING
19316 Mastoplexy
REFERENCES
1. Regnault P. Breast ptosis. Definition and
treatment. Clin Plast Surg. 1976;3:193–203.
2. Lemmon JA. Reduction mammaplasty
and mastopexy. Sel Readings Plast Surg.
2008;10:1–51.
3. Erol O, Spira M. Mastopexy technique for
mild to moderate ptosis. Plast Reconstr
Surg. 1990;65:603–609.
4. Gruber RP. The “donut” mastopexy: indica-
tions and complications. Plast Reconstr
Surg. 1980;65:34–38.
5. Spear SL. Guidelines in concentric masto-
pexy. Plast Reconstr Surg. 1990;85:961–968.
6. Puckett C. Crescent mastopexy and
augmentation. Plast Reconstr Surg.
1985;75:533–544.
7. Goes JCS. Periareolar mammaplasty:
double skin technique with application of
polyglactin or mixed mesh. Plast Reconstr
Surg. 1996;97:959–968.
8. Bartels RJ, Strickland DM, Douglas WM.
A new mastopexy operation for mild or
moderate breast ptosis. Plast Reconstr Surg.
1976;57:687–691.
9. Spear SL. Concentric mastopexy revisited.
Plast Reconstr Surg. 2000;107:1294–1299.
10. Mugea TT. Rules in breast aesthetic surgery.
Paper presented at the Fourth International
Congress of Romanian Aesthetic Surgery
Society, Bucharest, Romania, October 3–5,
2002.
11. Benelli L. A new periareolar mammaplasty:
round block technique. Aesthetic Plast Surg.
1990;14:93–100.
12. Hammond D. Short scar periareolar i­nferior
pedicle reduction (SPAIR) ­mammaplasty.
Plast Reconstr Surg. 1999;103:890–891.
13. Lassus C. Vertical scar breast reduction and
mastopexy without undermining. In: Spear
SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia, PA: Lippincott-Raven;
1998, pp. 356–359.
14. Lejour M, Abboud M. Vertical mammo-
plasty without inframammary scar with
breast liposuction. Perspect Plast Surg.
1990;4:67–72.
15. Lejour M. Vertical mammaplasty for
breast reduction and mastopexy. In: Spear
SL, ed. Surgery of the Breast: Principles
and Art. Philadelphia, PA: Lippincott-
Raven; 1998, pp. 391–393.
16. Lassus C. Breast reduction: evolution of a
technique—a single vertical scar. Aesthetic
Plast Surg. 1987;11:107–112.
17. Lassus C. Vertical scar breast reduction and
mastopexy without undermining. In: Spear
SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia, PA: Lippincott-Raven;
1998, pp. 360–361.
18. Graf R, Biggs TM. In search of better shape
in mastopexy and reduction mammaplasty.
Plast Reconstr Surg. 2002;110:309–317.

19. Wise RJ. A preliminary report on a method
planning the mammaplasty. Plast Reconstr
Surg. 1956;17:367–375.
20. Pitanguy I. Surgical treatment of
breast hypertrophy. Br J Plast Surg.
1967;20:78–85.
21. Nicolle F, Chir M. Improved standards in
reduction mammaplasty and mastopexy.
Plast Reconstr Surg. 1982;69:453–457.
References 221
22. Peixoto G. Reduction mammaplasty:
a personal technique. Plast Reconstr Surg.
1980;65:217–226.
23. Caldeira AM, Lucas A, Grigalek G.
Mastoplasty: the triple flap ­interposition tech-
nique. Aesthetic Plast Surg. 1999;23:51–60.
24. Flowers RS, Smith EM. “Flip-flap”
­mastopexy. Aesthetic Plast Surg.
1998;22:425–429.
 25
Abdominoplasty, panniculectomy,
and belt lipectomy*

ARI S. HOSCHANDER, JUN TASHIRO, AND CHARLES K. HERMAN

Introduction 223 Notes 226

Preoperative markings 223 CPT coding 227
Intraoperative details 224 References 227
Postoperative care 226 Acknowledgment 227

INDICATIONS

1. Removal of excess abdominal skin while 2. Rectus muscle diastasis

restoring the structural integrity of the
anterior abdominal wall

Table 25.1  Special equipment

Jackson-Pratt drains, size 19F, 1 per side

INTRODUCTION PREOPERATIVE MARKINGS

Abdominoplasty offers patients aesthetic improve-
ment of body contouring, as well as the restoration
of the defining structures of the abdominal wall.
By correcting abdominal wall laxity and resecting
excess skin and tissue, abdominoplasty restores the
abdomen to a more desirable aesthetic form. When
circumferential contouring is desired, a body lift
may be considered especially in the massive weight
loss patient. Table 25.1 indicates special equipment
needed for the procedure.
The patient should be marked in the standing
­position in the preoperative holding area.
1. Midaxillary lines and a horizontal waistline
should be marked to ensure a symmetrical
outcome.
2. For the lower border of the resection, the
suprapubic line above the mons pubis is
extended laterally in the groin crease. This
line must be greater than 5 to 7 cm superior

* Abdominoplasty video available at http://goo.gl/A4NIhn

223
224  Abdominoplasty, panniculectomy, and belt lipectomy

to the vulvar commissure. From there, lines

are extended toward the anterior superior iliac
spine (ASIS) to stay within the bikini line.1,2
3. An estimate of the superior border of resec-
tion may be marked preoperatively. However,
an exact superior border of the resection must
be drawn intraoperatively once the flap has
been raised, the umbilical stalk freed, and the
patient positioned properly to determine the
appropriate amount of the resection.

INTRAOPERATIVE DETAILS
1. Incise the inferior elliptical border using a
#10 scalpel. Extend the incision through the
dermis with monopolar electrocautery on
the pure cut setting, leaving the majority of
dermis on the lower skin flap.
Note: Some surgeons prefer to inject a
­tumescent solution consisting of 25 mL 1%
xylocaine with 1:100,000 epinephrine diluted
in 1 L normal saline along the incision lines
prior to the initial incision to ensure hemosta-
sis and provide additional anesthesia.2
2. Carry the incision down through subcu-
­plication markings.
taneous tissue and Scarpa fascia, ensuring
hemostasis at all times. The application of
hemaclips may be required to ligate perforator
vessels to achieve excellent hemostasis.
3. Identify the anterior rectus sheath.
4. Raise a flap superficial to the anterior rectus
sheath up to the level of the umbilical stalk.
5. Replace the abdominal flap and turn atten-
tion to the umbilicus. Using two single-prong
hooks at the 12-o’clock and 6-o’clock posi-
tions, raise the umbilicus. Incise around the
umbilicus with a #15 scalpel. Mobilize
the stalk using sharp dissection, down to the
rectus fascia.
6. Once the stalk is mobilized, extend the flap
superiorly to the level of the xiphoid process,
beginning at the upper border of the resec-
tion. Be sure to stay centrally and preserve as
many lateral perforators of the upper abdomi-
nal flap as possible. Irrigate the wound copi-
ously and inspect for hemostasis.
7. Mark vertical lines for fascial plication (see
Figure 25.1). The purpose of these lines is to
approximate the medial edges of the rectus
abdominis muscles, which have separated
with weight gain over time, causing diastasis
Figure 25.1  Supraumbilical flap with fascial
and loss of structured contour. Place ­fascial
plication sutures in a figure-of-eight fash-
ion using a size 0 Ethibond Excel® (Ethicon,
Somerville, NJ) suture. Imbricate the suture
lines with a second layer to ensure smooth
plication (see Figure 25.2). To further enhance
the definition of the waistline inferiorly,
additional plication sutures may be placed
within the external oblique fascia laterally.
Again, irrigate the wound copiously and
inspect for hemostasis. It is important to
check the airway pressures with the anesthesia
team prior to this plication. Any significant
change in pressure should be addressed, and
the removal of plication sutures should be
considered.
8. Flex the operating table at the level of the
patient’s hips to ensure adequate mobilization
of the abdominal flap and to verify and adjust
the superior border of resection.
9. Drape the upper abdominal flap over the
lower border incision in a “vest-over-pants”
fashion to determine the final margin of
­excision from the upper flap (see Figure 25.3).

Figure 25.2  Abdomen with fascial plication
sutures in place.
The preoperative marking for the superior
border must be adjusted according to the
­portion of the flap remaining in excess when
the patient is placed in a flexed position.3
10. Excise this skin and subcutaneous tissue with
a scalpel and electrocautery.
11. At this point, place three 3-0 Monocryl®
(Ethicon) sutures in the rectus fascia and
through the dermis of the umbilical stalk at
the 2-o’clock, 10-o’clock, and 6-o’clock posi-
tions. These sutures should be protected and
left attached. The tails should be clamped with
small clamps and retained until the umbilical
incision is created.
12. Place temporary or permanent tacking sutures
in the Scarpa fascia and skin of the mid-
line of the abdominal flap to secure it to the
lower flap.
13. Mark the final position of the umbilicus
within the abdominal flap by placing a
right-angle clamp on the umbilicus beneath
the skin flap, aiming the clamp toward the
anterior abdominal skin flap. Locate this
Intraoperative details  225
Figure 25.3  Determining upper border of
­resection by draping flap over lower e­ lliptical
border in a vest-over-pants fashion; note
­transposition of umbilicus.
position on the skin of the abdominal flap.
Place a heart-shaped incision approximately
1 cm cephalad to this mark. Incise this mark
with a #15 scalpel and carry the incision down
through all the layers of the abdominal flap.
14. Using the three 3-0 Monocryl sutures from
the umbilical dermis, secure the ­umbilicus to
the equivalent positions in the umbilical inci-
sion of the abdominal flap.
15. Make a small incision in the 12-o’clock posi-
tion of the umbilicus. Inset the deep, central
corner of the heart into this incision in the
stalk with 3-0 Monocryl sutures.
16. Place several additional interrupted 3-0
Monocryl sutures in the umbilicus to secure it
to the abdominal flap.
17. Place half-buried, horizontal mattress sutures
using 5-0 Ethilon® (Ethicon) circumferen-
tially around the umbilicus.
226  Abdominoplasty, panniculectomy, and belt lipectomy
18. Place a 15F Jackson-Pratt drain at the lateral
corners of the wound on either side, exit-
ing within the pubic hair region. Secure the
drains externally using a 3-0 Ethilon suture.
19. Close the wound using 2-0 Monocryl suture
in an interrupted fashion to close the Scarpa
fascia, followed by 3-0 Monocryl suture
in an interrupted fashion for the dermal
layer. Close the skin using 4-0 Monocryl
suture in a running subcuticular fashion.
Reinforce the closure using Dermabond®
(Ethicon).
20. Place a standard abdominal binder over light
surgical dressings immediately following the
procedure to allow for healing of the plica-
tion sutures and to reduce the risk of seroma
formation.
POSTOPERATIVE CARE
Patients can be discharged home within 24 hours
if medically stable. Continuous use of the binder
is recommended for 3 weeks following the pro-
cedure. The nonabsorbable umbilical sutures are
removed at the postoperative office visit in approx-
imately 1 week. The Jackson-Pratt drains are left in
place until output is less than 30 mL in 24 hours for
3 consecutive days or at 3 weeks postoperatively,
whichever is earlier. The importance of monitor-
ing drain outputs must be relayed to the patient
as seroma formation is associated with poor out-
comes and complications.4 Patients should be cau-
tioned against heavy lifting or strenuous physical
activity for a minimum of 6 weeks following the
procedure.
NOTES
For the panniculectomy procedure, the major dif-
ference is the lack of abdominal tissue transposi-
tion and fascial plication. Panniculectomies are
performed solely for the purpose of reducing the
risk of panniculitis and related complications.
Health insurance companies determine coverage
of this procedure strictly based on this distinction.
A similar resection of the infraumbilical pannus
is performed, although the contouring portion,
including umbilical transposition, is not com-
pleted as described in the abdominoplasty proce-
dure described above (i.e., steps 4 through 7 are
omitted). Panniculectomy incisions are generally
closed with skin staples; by nature, these wounds
are at increased risk of infection postoperatively.
For a belt lipectomy procedure, the major dif-
ference is the circumferential resection, combin-
ing a back-lift procedure with an abdominoplasty.
This procedure is targeted toward reconstruction
and improvement of body contour in patients with
large deposits of excess adipose tissue anteriorly
and posteriorly, with both upper and lower abdom-
inal fullness.3 The major steps are:
1. Preoperative marking differs to include
the torso circumferentially. After marking
the anterior resection as described earlier, the
patient’s back is then marked. The major dif-
ference in the marking of the anterior portion
is that the lateral markings from the superior
line and inferior line do not meet each other
but instead will meet the superior and inferior
incisions from the posterior resection.
2. The tissue of the lower back is smooth until
the level of the buttocks, which is used to
mark the extent of the inferior border of the
resection. Pinch the tissue above this line to
simulate the resection without tension. Mark
and extend this line laterally from the midline
to meet the superior and inferior marks of the
anterior resection.
3. Place the patient in the prone position, prep,
and drape in sterile fashion.
4. A #10 scalpel is used to incise along the
inferior border. Deepen the incision using
monopolar electrocautery to the level of the
fascia.
5. Raise a flap superiorly, of only tissue that is
going to be excised, to the level of the pre-
dicted superior border of resection. Place
tailor tack sutures (e.g., 0 Prolene®, Ethicon)
in an interrupted fashion to simulate the final
resection border.
6. Once the patient is placed in the flat prone
position, use a #10 scalpel to incise along the
superior border. Carefully resect the excess
subcutaneous tissue from the lower back
above the fascial layer. Irrigate the area with
copious amounts of normal saline and check
for achievement of hemostasis.
7. Do not undermine the flaps during the
posterior resection; this will help to limit
seroma formation. Seromas in this region
can be particularly problematic. Leave two

15F Jackson-Pratt drains in place and pull
through the skin to be connected to bulb suc-
tion. Secure using 3-0 Ethilon suture.
8. Close the deep layers of subcutaneous tissue
using 2-0 Vicryl® (Ethicon) suture, followed
by 3-0 Monocryl suture for the remainder of
the subcutaneous tissue. Close the skin using
4-0 Monocryl suture in a running subcuticu-
lar fashion. Note that at the lateral margins
of the incision, the wound will not be closed
until the patient is placed supine and the ante-
rior resection is accomplished. While turning
the patient, these open areas can be covered
with semi-occlusive dressings.
9. A sterile dressing is applied to the entire
wound.
10. Turn the patient to the supine position
and then prep and drape in sterile fash-
ion again. Following this step, a standard
abdominoplasty procedure is performed, tak-
ing care to connect the superior and inferior
borders of the back-lift resection to the respec-
tive borders of the abdominoplasty. Another
alternative to this is to circumferentially prep
the patient in the standing position prior to
induction of anesthesia and then to begin
prone and using sterile technique, turn into
the supine position.
CPT CODING
15830 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); abdomen, infraum-
bilical panniculectomy
Acknowledgment 227
15833 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); thigh
15834 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); hip
15835 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); buttock
15847 Excision, excessive skin and subcutane-
ous tissue (includes lipectomy); abdomen
(e.g., abdominoplasty), includes umbilical trans-
position and fascial plication (list separately
in addition to code for primary procedure)
(Note: use in conjunction with 15830)
15877 Suction-assisted lipectomy, trunk
REFERENCES
1. Mathes SJ, ed. Plastic Surgery. 2nd ed.,
Vol. 6. Philadelphia, PA: Saunders Elsevier;
2006.
2. Guyuron B, ed. Plastic Surgery: Indications,
Operations, and Outcomes. Vol. 5. St. Louis,
MO, Mosby; 2000.
3. Aly AS, Cram AE, Chao M, Pang J, McKeon M.
Belt lipectomy for circumferential truncal
excess: the University of Iowa experience.
Plast Reconstr Surg. 2003;111(1):398–413.
4. Buck DW, Mustoe TA. An evidence-based
approach to abdominoplasty. Plast Reconstr
Surg. 2010;126(6):2189–2195.
ACKNOWLEDGMENT
We are grateful for the artistic contribution of
Kriya Gishen.
 26
Brachioplasty

ANSELM WONG, SAMANTHA ARZILLO, AND WROOD KASSIRA

Introduction 229 Notes 232

Preoperative markings 230 CPT coding 232
Intraoperative details 230 References 232
Postoperative care 231

INDICATIONS

1. Massive weight loss, such as following 2. Skin laxity exceeds subcutaneous fat in the
bariatric surgery upper arm and possibly lateral chest regions

Table 26.1  Special equipment

Ancef 1 g IV given prior to incision (clindamycin 600 mg IV if allergic to penicillin)
Lower-body Bair hugger, sequential compression devices to bilateral lower
extremities, proper padding of arm boards, pulse oximeter on ear or toes
Sterile antiseptic skin preparation
Methylene blue for marking
Lidocaine with epinephrine
Protected Bovie tip
Jackson-Pratt 19F round drain
BioPatch® (Ethicon)
Dermabond

INTRODUCTION for this operation is someone who has recently lost

Brachioplasty is a surgical procedure performed
on individuals with excess skin laxity in the upper
arm and may include the lateral chest area.1–4 These
deformities often cannot be smoothed and toned
by diet and exercise alone. A common candidate
a great deal of weight, for example, a patient with
massive weight loss after gastric bypass.1–5 As a
result, the upper arms have an overabundance of
skin. Liposuction alone removes fat but does not
tighten the excessive skin; this often results in skin

229
230 Brachioplasty
irregularities and deformities. A brachioplasty is
designed to remove both the excess skin and the
subcutaneous fat.4 Although the patient is left with
a rather long scar, there are benefits to this surgery,
including improved self-esteem and increased ease
of dressing, and the scar itself may be hidden so it
is minimally visible.2 However, patients need to be
counseled on the risks, benefits, and alternatives of
proceeding with brachioplasty. In addition to the
usual risks of body-contouring procedures, risk
of hypertrophic scarring, lymphedema, seroma,
injury to the medial antebrachial cutaneous nerve
with resulting pain, paresthesias, or numbness need
to be emphasized to the patient. Care must be taken
not to excise too much skin so that closure without
excessive tension can be performed. Table 26.1 indi-
cates special equipment needed for the procedure.
PREOPERATIVE MARKINGS2,4
1. The patient is marked in a standing position.
2. Abduct and adduct each arm to determine the
level of the axillary crease.
3. With the patient’s arm abducted at 90° and
with the elbow flexed at 90°, pinch along the
upper arm to draw a series of anterior and
posterior marks.
4. If redundancy of tissue extends to the axilla and
lateral chest, repeat the pinch test along the lat-
eral chest wall along the posterior axillary fold.
5. These markings are connected to form the
outer ellipse (Figure 26.1).
6. To allow for the distance between the pinching
fingers, mark an inner ellipse to allow enough
remaining skin to re-approximate following
resection.
A
A
B
Figure 26.1  Preoperative markings.
7. Make crosshatch marks to help with closure.
8. Draw a central line through the ellipse to
approximate the final scar.
INTRAOPERATIVE DETAILS
1. Inject methylene blue to tattoo the markings.
2. Inject the lidocaine and epinephrine along the
proposed incision sites to decrease intraopera-
tive bleeding.
3. Double-check the markings by stapling along
the inner ellipse; adjust the marks if the pro-
posed closure appears too tight.
4. The operation proceeds from a distal-to-­
proximal direction.
5. Place retraction clamps along the inner ellipse
to provide traction during resection.
6. Make the anterior incisions along the ellipse
up to the first crosshatch mark.
7. Raise the skin and subcutaneous fat as a
posteriorly based flap, keeping the plane
of dissection just above the muscle fascia
(Figure 26.2).
8. After reaching the first crosshatch, provision-
ally close the area with staples to prevent
edema in that segment.
9. If the closure is too tight, re-introduce the
flap back into the wound and adjust the
­resection line.
10. Continue the resection to the next segment
and staple/adjust in a similar fashion until the
axillary crease is reached (Figure 26.3).
11. At the level of the axillary crease, dissect
more superficially to avoid damage to the
lymphatics.
C
 Postoperative care  231

A C
B

Figure 26.2  Skin and subcutaneous fat raised as a posteriorly based flap.

A C
B

Figure 26.3  Crosshatching of skin flap.

C
B

Figure 26.4  Final skin closure.

12. If there is concern for postoperative
­contracture at the axillary crease, a Z-plasty
may be performed.
13. Introduce the Jackson-Pratt drain in the
wound through an incision at the lateral chest
wall or distal arm if the lateral chest extension
is not performed.
14. Close the deep layer of the arm with 3-0
Vicryl® (Ethicon, Somerville, NJ) inter-
rupted sutures, followed by intradermal 3-0
Monocryl® (Ethicon) buried interrupted
sutures.
15. The final skin re-approximation is performed
with a running subcuticular 4-0 Monocryl
suture and reinforced with Dermabond®
(Ethicon) (Figure 26.4). Kerlix™ (Covidien,
Dublin, Ireland) and Ace™ (3M, St. Paul, MN)
wraps are used to wrap the upper extremities.
POSTOPERATIVE CARE
If a brachioplasty is the only procedure performed,
the patient may be discharged the same day.4 If the
procedure is combined with another operation,
232 Brachioplasty
such as a mastopexy, the patient should be ­admitted
overnight for observation. Whenever possible, the
arms are to be kept elevated above the heart, with
the elbows slightly flexed, for 3 weeks.4
When the discharge in the drains is less than
30 mL in a 24-hour period, the drains may be
removed; this usually takes place within the first
week. Following this, the patient should wear com-
pression garments that extend to the hands for a
total of 2 to 3 months.5
NOTES
Care must be taken to avoid injuring the ulnar and
medial antebrachial cutaneous nerves, as well as
lymphatics in the area.2,3 Patients should be cau-
tioned preoperatively that possible complications
of the surgery include numbness, lymphedema,
and seroma formation in addition to the usual
postoperative complications.2–4
CPT CODING
15836 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); arm
REFERENCES
1. Strauch B, Greenspun D, Levine J, Baum T.
A technique of brachioplasty. Plast Reconstr
Surg. 2004;113(3):1044–1048.
2. Symbas JD, Losken A. An outcome a ­ nalysis
of brachioplasty techniques f­ ollowing
massive weight loss. Ann Plast Surg.
2010;64(5):588–591.
3. Gusenoff JA, Coon D, Rubin JP.
Brachioplasty and concomitant procedures
after massive weight loss: a statistical
analysis from a prospective registry. Plast
Reconstr Surg. 2008;122(2):595–603.
4. Aly A, Soliman S, Cram A. Brachioplasty in
the massive weight loss patient. Clin Plast
Surg. 2008;35(1):141–147.
5. Trussler AP, Rohrich RJ. Limited incision
medial brachioplasty: technical refinements
in upper arm contouring. Plast Reconstr
Surg. 2008;121(1):305–307.

Medial thigh lift
DENNIS J. HURWITZ
Introduction 234
Preoperative markings 234
Intraoperative details 235
INDICATIONS
1. Undesirable skin laxity and adipose excess
of the anterior and medial thighs which is
correctable by a medial thigh lift (MTL).
2. The patient is cognitively and psychologically
cleared for the treatment. Inappropriate
behavior prompts psychological screening
and referral as indicated.
3. The patient understands the aesthetic
goals, basic technique, and placement and
unpredictability of the scars, as well as the
common risks of a MTL. Then the patient signs
written consent form.
4. Chronic skin diseases, swelling, lymphatic,
venous or arterial insufficiency are
investigated and if not resolved will probably
contraindicate surgery.
5. General medical condition, nutrition, and
anemia are noted and improved as needed
or the patient is rejected. Massive weight
loss patients receive special supplements.
History and physical examination and
selected laboratory studies identify
27
Postoperative details 241
CPT coding 245
References 245
general or selected malnutrition that
should be corrected for optimal wound
healing. Obesity is treated by weight loss
and if the patient is unable then patient
is offered a highly regimented 42-day,
500-calorie-a-day diet plan with HCG
(human choriogonadotrophic hormone)
single-syringe injections. The daily
management is by the physician assistant.
6. Whenever possible, our aestheticians
institute a special package of twice-weekly
Lipomassage (Endermologie, LPG, Paris,
France) 45-minute sessions for 3 weeks
prior to surgery. The mechanico-stimulation
activates supportive collagen synthesis,
softens adiposity and improves blood flow.
Subsequent liposuction appears less traumatic
and hemorrhagic. The patient has been
prepared for her routine postoperative
Lipomassage. If the patient expresses
unrealistic expectations during this
preparation, then thigh lift is reconsidered.
233
234  Medial thigh lift
Table 27.1  Special equipment
Ultrasonic-assisted lipoplasty equipment (LySonix or Vaser)
Rapid saline infusion and aspirating liposuction system with 4-mm cannulas
#1 or #2 PDO Quill suture
3-0 Monoderm Quill suture
Indermil® (Henkel, Dusseldorf, Germany) or Dermabond® (Ethicon) skin glue
Large Marena (Marena Group, Lawrenceville, GA) long-leg tights
INTRODUCTION
Medial thigh lift (MTL) encompasses a wide
range of operations and procedure combinations
dictated by the extent of thigh and lower torso
deformity and the patient’s expectations. MTL is
essentially an excision of medial thigh skin, fol-
lowed by closure with superior suspension, result-
ing in tighter and lifted thigh skin. The most
limited MTL is a horizontal crescent excision from
the mons pubis to the ischial tuberosity inferior
to the labia majora. The advanced medial thigh
flap is anchored to Colles fascia to avoid inferior
drift of the scar.1 The horizontal excision may be
extended posteriorly beyond the tuberosity along
the infragluteal fold to the lateral trochanter to lift
the posterior thigh and define the inferior border
of the buttocks. The excision may also be extended
anteriorly to beyond the mons pubis to the groin
as part of an abdominoplasty. With both posterior
and anterior extensions, the horizontal excision
takes a spiral turn from posterior across medial
to the groins; hence the term spiral thighplasty.2
Regardless of the extensions, the superior horizon-
tal excision lifts roughly only the upper third of the
thigh. A mid-medial vertical excision will remove
laxity along the mid- to distal medial thigh. The
excision is taken as far distally as necessary to
tighten loose thigh skin.
This chapter’s vertical MTL description reflects
a recent clinical case that also included a lower
body lift (LBL). The patient was a 42-year-old
woman, with a body mass index (BMI) of 24.7, who
lost 100 pounds through a gastric bypass 3 years
prior to requesting surgery to improve her lower
torso and thighs. She had a prior abdominoplasty
and bilateral brachioplasty. This operation started
supine with the upper oblique and horizontal por-
tions at the same time as the vertical portion of
the thighplasty (Figures  27.1–27.5). She was then
turned prone for completion of the operation
(Figures  27.6–27.9). Table  27.1 lists the special
equipment for the procedure.
PREOPERATIVE MARKINGS
1. Evaluate skin laxity and adipose tissue of the
anteromedial thigh. With the patient stand-
ing and turning 360°, judge the extent of
­deformity and asymmetry. Observe skin drap-
ing, laxity, and bulging contours. As the skin
is pushed up, observe the result of gathered
tissues across the medial thigh. Estimate the
extent of liposuction and skin excision width
along the length of the thigh.
2. If the skin laxity is minimal and adiposity
excessive, consider preliminary total thigh
liposuction. Avoid combining extensively
liposuctioned thighs with advancement flaps
closed under tension because delayed healing
and seroma due to trauma and ischemia are
potentiated. As a first stage, extensive prelimi-
nary liposuction may leave considerable subcu-
taneous scarring and contour irregularities that
challenge subsequent thighplasty. Otherwise,
if there is sufficient medial thigh laxity and only
limited liposuction is needed, proceed with a
thigh lift under moderate closure tension.
3. Consider indications for concomitant abdomi-
noplasty, posterior thigh lift, mons pubic
plasty, or LBL with or without gluteal augmen-
tation. The thighplasty described in this chap-
ter is combined with an LBL and a posterior
thighplasty. When a posterior thighplasty is
included, the thigh lift incorporates a spiral-
shaped excision of skin starting at the gluteal
thigh junction that winds around the upper-
most medial thigh and then extends across the
groin to across the hips.2
4. Having just examined the patient standing,
start markings with the patient supine, right
knee flexed and the thigh abducted. Draw a

line at the junction of the right labia majora
and the medial thigh, continuing it straight
up the lateral mons pubis and inferiorly to
the palpated ischial tuberosity (Figure 27.1,
line 2).
5. With the knee still flexed, the right leg is
adducted. Loose medial thigh skin falls
toward the labia majora. Mark the widest
point. From there, mark a second line roughly
parallel to the first to conservatively excise a
transverse crescent of superior medial thigh
skin between the pubis and ischial tuberosity
(Figure 27.1, line 3).
6. Anterior thigh skin is pulled medially with
the surgeon’s helping hand to mark a ­vertical
line just posterior to the medial meridian
of the thigh from the pubic insertion of the
adductor magnus tendon to the medial knee
(Figure 27.1, line 4).
7. At the mid-portion of the thigh, the tissues
are squeezed together, with a point made
posterior to the first line at the greatest width
of anticipated skin resection.
8. The distal posterior line is drawn from that
point, tapering to the medial knee. The line
is adjusted for adequacy of resection by again
gathering the tissues along the just-marked
lines.
9. Proximal continuation of this posterior line
is tapered superiorly to meet the previously
drawn lateral labia line. Gather this posterior
and previously drawn anterior incision line to
confirm adequate width of proximal medial
thigh resection (Figure 27.1, line 5).
10. Finally, the anterior line is curved upward to
the groin, allowing for an adequate width of
skin resection to the labia and pubis.
11. Pinch closure of the proximal proposed resec-
tion adequately advances upper posterior
thigh excess. See Figure 27.1 for explanation of
lines 6 and 7 for the LBL.
12. While the patient is being induced under
­anesthesia, equipment access and infu-
sion ­fluids are checked. Ultrasonic-assisted
lipoplasty (UAL) is my treatment of choice
with both the LySonix® 3000 (Mentor
Corporation, Santa Barbara, CA) and Vaser®
(Sound Surgical Technologies, Louisville, CO)
systems. Usually, the VASERlipo with low
pressure VentX suction cannulas is selected.
A labeled 3-L bag of saline with 5 mg
Intraoperative details  235
epinephrine and 120 mL 1% xylocaine hangs
above the roller infusion pump.
13. The patient is centered on the operating room
table and her body temperature checked. If
the patient’s temperature is less than 36°C,
then the infusion and intravenous fluids are
warmed and the operating room temperature
is lowered. When multiple procedures or
high-volume liposuction are planned, a Foley
catheter is inserted.
14. The supine patient is placed in a frog-leg
position with egg crate foam protecting the
foot and ankles. The patient is prepped with
ChloraPrep® (CareFusion, Vernon Hills, IL)
and draped in a sterile manner. Squeeze the
proposed skin incisions together and tailor
tack with staples, sutures, or towel clamps if
you wish for a final check for the appropri-
ateness of the width of resection and adjust
markings accordingly.
INTRAOPERATIVE DETAILS
1. Liposuction of the excision site is the first
intervention. Stab wound incisions are
placed within the planned excision site for
the infusion of saline followed by two-step
UAL. Additional stab wounds allow for saline
infusion in selected cosmetic fat reduction
areas. The saline with xylocaine and epi-
nephrine is infused through a closed roller
pump intravenous system through a Hunsted
multihole blunt cannula. If the excision site
is the only area to be suctioned, then care is
taken to limit infusion to within the circum-
scribed area. Otherwise, the cosmetic adipose
excesses are also infiltrated. Infusion is lay-
ered from subdermal to muscular fascia until
the subcutaneous tissues are uniformly full
and firm but not tense.
2. UAL thoroughly aspirates fat from under the
preplanned area of medial skin resection. The
power on the generator is set around seven.
The long, hollow aspirating probe with the
aggressive golf tee tip is rhythmically and
slowly pushed back and forth a long excursion
to thoroughly emulsify the excision site fat
(Figure 27.2a). A continuous yellow emul-
sion slowly flows through the low-pressure
suction tube. Absence of tissue resistance
with a uniform flattening of the treated area
236  Medial thigh lift

Figure 27.1  Spiral thighplasty with a vertical medial extension and the lower body lift (LBL) in 42-year-old
massive weight loss (MWL) patient. The buttock segment of the LBL will be deepithelialized for adipose
flap augmentation. The drawn lines are numbered in sequence. The initial line is a midline vertical (1) from
umbilicus to labia majora commissure. There is no skin excess to be excised along the lower abdominal
midline. That line guides symmetry. Equidistant from either side of the midline, a vertical line (2) is drawn
down the lateral mons pubis and in the junction between the labia majora and medial thigh. As part of
the spiral thighplasty, that line continues to the ischial tuberosity and then along the gluteal fold when the
patient is turned. With the right hip and knee flexed, the medial thigh skin falls to the mons pubis. The
excess skin is marked, and through this mark, the inferior line (3) of the upper thigh crescent excision is
drawn. With the right leg slightly abducted and the anterior thigh skin dragged medially, a vertical line (4)
along the medial meridian is drawn to the medial knee. From that line in the middle of the thigh, a pinch
test leads to marking the width of resection of the vertical excision. A long, tapered posterior line (5) com-
pletes the medial vertical ellipse. The horizontal incision lines (2, 3) of the medial thighplasty taper almost
together as they cross the groins on the way to the anterior superior iliac spines (ASISs). From there, supe-
rior anchor lines (6) are drawn straight across the hip and back to meet several centimeters superior to the
gluteal cleft. This horizontal anchor line (6) holds the suspension from the advanced inferior flaps. Along
the lateral thigh, the excess skin is pinched to the superior line, with the widest point at the saddlebag
deformity. The inferior incision line (7) descends to that point at which, through grasping, the lateral thigh
no longer sags. Then, the inferior line (7) proceeds across the buttocks to the top of the intergluteal cleft.
Most of the posterior portion of the LBL excision is deepithelialized and stacked for buttock augmentation.
The overhanging inferior buttocks obscure most of the planned excision at the buttock thigh junction.
 Intraoperative details  237

(a)

(b)

Figure 27.2  Operation starts with the patient supine. (a) The operator incises skin and fat from the
left groin as an assistant holds a gulf-tip LySonix cannula over the right side excision site. (b) The
depressed right thigh excision site indicates completion of radical excision site liposuction. Ultrasonic-
assisted lipoplasty (UAL) of the right thigh begins. There is full-thickness skin and fat resection of the
left lateral thigh and partial thickness fat removal from the lower abdomen and groin. A LaRoux dis-
sector is partially inserted over the fascia lata of the thigh to spread for discontinuous undermining.
238  Medial thigh lift

(a)

(b)

Figure 27.3  Left hip closure. (a) Four deep throws of #2 PDO Quill start the deep closure of the left
hip wound. (b) Wound edges are approximated by pulling both ends.

indicates ­adequacy of ultrasonic applica- neurovasculature than traditional l­ iposuction

tion (Figure 27.2b). Traditional liposuction
through a 4- or 5-mm cannula then com-
pletes the removal of most of the excision
site fat. Based on post-liposuction wound
observation, it appears that UAL better pre-
serves subcutaneous tissue architecture and
alone.
3. When indicated, cosmetic reduction of fat
excess is performed as previously marked.
During the liposuction, care is taken to main-
tain untreated full thickness of the subcu-
taneous tissue along the wound edge so that

(a)
(b)
Figure 27.4  PDO Quill closure. (a) Two horizontal bites are taken on either side of the initial stitch.
(b) The wound is closed by pulling on the sutures.
there will be secure and non-depressed wound
closure. Vigorous UAL along the incision
could lead to skin flap necrosis and should be
avoided.
4. While pulling the medial skin anterior, an
incision is made perpendicular through
skin, subcutaneous tissue, down to muscular
Intraoperative details  239
fascia along the entire length of the posterior
­incision markings.
5. By pushing the entire resection incision lines
together, a final adjustment of the width along
the resection allows for adjustments. Then, the
entire length of the adjusted anterior incision
is made.
240  Medial thigh lift
6. Preceding from distal to proximal, the skin
is removed as if harvesting a composite skin
graft. Using a scalpel with a #10 blade and a
Freeman six-prong hook retractor, the cutting
is against the white dermis (Figure 27.4a, right
leg). Countertraction with the helping hand is
against the defatted subcutaneous bed to pre-
serve as much of the stringy dermal attach-
ments as possible.
7. Electrosurgical dissection is not necessary
because there is minimal bleeding, mostly
from partially cut veins, which is easily
controlled.
8. When the MTL is an isolated procedure, the
posterior incision is continued anteriorly
along the medial thigh genital groove to the
mons pubis.
9. The anterior medial thighplasty incision
is turned toward the groin for a conser-
vative width (3 to 6 cm) crescent-shaped
resection of the upper transverse thigh
(Figure 27.4a).
10. If the wound edges are inverted, they are
undercut for 1 to 2 cm; otherwise, no under-
mining is performed.
11. At the mid-thigh, the surgeon manually
approximates the anterior and posterior thigh
skin flaps. If the flaps can be easily over-
lapped, then an additional centimeter or two
of wound edge is excised along the vertical
incision.
12. The closure at the mid-thigh is temporarily
held with several towel clips. Thick wound
edges with considerable tension across the
closure suggest a #2 PDO (­polydioxanone),
24-cm Quill™ (Surgical Specialties
Corporation, Vancouver, BC, Canada) suture
on 38-mm taper needle.
13. Starting at the mid-thigh, two deep ver-
tical bites are taken in either direction
(Figure 27.4a) and then by pulling on the
ends, the four throws approximate the center
of the closure (Figure 27.4b). Ideally, one
operator sutures from each end, taking two
deep horizontal bites of the subcutaneous tis-
sue before a cinch pull. At the distal termina-
tion at the knee, the final horizontal passes
end in a J-shaped return. The proximal suture
ends several centimeters before the labia
majora and returns for a few bites to lock in
the retention.
14. The proximal horizontal crescent
shape e­ xcision is reevaluated. If a
­contemporaneous abdominoplasty is being
performed, that ­i nitial closure must be
completed before excising the crescent. That
order is necessary because the abdomino-
plasty closure will pull up on the anterior
thigh skin.
15. After adjusting the width of the upper thigh
crescent excision, the skin from lateral to
the pubis to the adductor magnus tendon is
excised without taking underlying fat to pre-
serve the densely layered lymphatic channels.
From the adductor tendon to the palpable
ischial tuberosity, underlying subcutaneous
tissue can be taken to the fascia lata of the
thigh.
16. When a width of more than several
­centimeters of skin is removed, the medial
anterior thigh flap is suture advanced with
two or three interrupted large permanent
braided sutures to genital Colles fascia and
lower pubic bone periosteum. The stitches
are placed and held with clamps. The leg
is moved from the frog-leg position to
straight and adducted. The sutures are then
tied. This medial anchoring of the anterior
thigh flap enhances the youthful rise to
the labia majora as well as retarding infe-
rior drift of the scar or lateral displacement
of the labia majora to even opening of the
introitus.
17. After confirming the adequacy of skin
removal, the upper thigh transverse
­crescent excision is then closed with a
­subcutaneous layer of 0 PDO Quill followed
by 3-0 Monoderm™ (Surgical Specialties)
Quill (Figure 27.5). Commonly, the posterior
extent of closure is centimeters beyond the
junction with the vertical closure toward
the ischial ­tuberosity. This T-junction
closure is vulnerable to occasional early
­postoperative wound breakdown. Careful
edge-to-edge approximation with tidying
up with s­ cattered interrupted 4-0 Prolene®
(Ethicon, Somerville, NJ) sutures can be
helpful.
18. Steri-Strips™ (3M, St. Paul, MN), or pref-
erably topical skin glue, is applied to the
suture line for support and coverage of
closure. The vertical medial thighplasty

Figure 27.5  Skin glue is applied to the two later closures at the completion of the operation in the
supine position with the legs abducted. Open wounds remain at hips and posterior medial thighs.
has been c­ ompleted. The patient was then
turned prone for her lower body lift with
buttock augmentation using deepithelialized
adipose fascial flaps and posterior thigh lift
with completion of the spiral thighplasty
(Figures 27.6 to 27.8).
1 9. The legs and lower torso are dressed with
appropriate size long leg tights with care not
to disrupt the closures. The patient is trans-
ferred from the operating room table to the
recovery room stretcher transport with no
adverse stresses on the thighs.
POSTOPERATIVE DETAILS
The patient is continued on intravenous fluids
and nasal oxygen. The condition, vital signs, and
thighs are frequently monitored. Pain is usu-
ally mild to moderate and readily treated with
small doses of intravenous narcotics. Excessive
pain is investigated by observation and palpa-
tion of the thighs for localized swelling and/or
drainage. When the thigh lift is an isolated pro-
cedure, the patient is discharged to home after
recovery from anesthesia. Low-dose oral narcotic
medications are prescribed. Prior to discharge
the thighs are examined through the garment
for dehiscence. If  wound s­eparation is sus-
pected, then the garment is unzipped and pulled
Postoperative details  241
down  for  better  examination. In the unlikely
event of a separation, the wound is closed with
interrupted skin sutures. With the incision com-
pletely closed, the patient is discharged when
she can walk, but is transported in a wheelchair
and accompanied by a trusted adult caretaker to
her vehicle. The patient is semi-recumbent in the
vehicle with the elastic garment released to relieve
binding across the lower abdomen. An opening in
the perineum allows for voiding and defecation.
While the patient may unzip the upper third of
the garment for perineal hygiene, pulling the gar-
ment off the thighs is discouraged. Removal may
disrupt wound edges by avulsing adherent skin
glue or Steri-Strips.
Within 24 hours of discharge, the patient
is telephoned. Early contact by the clinician is
appreciated and reassuring and may uncover a
misunderstanding in care or treatable problems.
The conversation usually starts with open-ended
questions on how the patient feels and her level
of pain. Complaints of feeling sick, chest pain,
shortness of breath, weakness, fatigue, inade-
quately controlled pain, or anxiety conjure con-
cerns for symptomatic acute anemia, pulmonary
embolism, sepsis, adverse drug reactions, or psy-
chological distress, prompting specific inquiries.
Also, the patient is routinely questioned about
nausea, return of appetite, intake of fluids, general
242  Medial thigh lift

(a) (b)

(c) (d)

Figure 27.6  LBL with autoaugmentation of the buttocks. (a) With the patient turned prone, the
­buttocks are spread out like a mushroom cap. (b) Flaps are deepithelialized with an ­electric
­dermatome. (c) Deepithelialized flaps are isolated on subcutaneous islands. (d) Left supragluteal
pocket is prepared to receive flaps.

activity, ­walking, diarrhea, and urine output. We
ask the status of drainage through the garment
and leg swelling. There should be very little of
each. Poor condition or probable serious adverse
events, including wound separation, require an
urgent visit to the office or even to the emergency
room. Short of that, concerns lead to a repeat call
within 24 hours.
The first office visit is 5 to 10 days after the opera-
tion. Adverse issues may prompt an earlier appoint-
ment, great travel distances a later visit. The garment
is unzipped and pulled down for the first  time.
 Postoperative details  243

(a)

(b)

Figure 27.7  Advancement of the buttock flaps. (a) Lateral portion of the right flap is flipped over and
advanced into the medial inferior extent of the pocket. (b) Matching flap augmentation is observed
from the head of the table.

The  closure is examined, and the scattered inter-
rupted skin sutures are removed. Lipomassage is
resumed and continued twice a week for 6 weeks.
Initially, the heads are set for edema resolution
and  the pressures lowered to accommodate pain.
The pressures are rapidly increased and the roller
direction changed to smooth tissue contours
and  hasten scar evolution. Monthly or bimonthly
maintenance to maintain skin elasticity, thick-
ness, and reduce cellulite is planned. Despite this
treatment, if the lower legs are edematous, a full-
leg sequential lymphatic treatment (lymphpress) is
initiated and the patient is given a machine for use
at home.
Minor wound separations are common, par-
ticularly at the T-junction at the labia majora.
244  Medial thigh lift

(a)

(b)

Figure 27.8  Posterior portion of the spiral thighplasty. (a) Bilateral adipose fascial flap augmentation
of the buttocks and LBL has been completed. An ellipse of skin and fat is drawn to be removed from
the right buttock thigh junction while the thighs are still abducted. (b) The legs are now adducted,
tightening the lateral thigh closures. Skin glue has been applied to all closures. Two 10-mm Jackson-
Pratt drains exit at hips.

With limited debridement and topical saline-
moistened gauze dressings, these wounds char-
acteristically heal without the need for secondary
closures or scar revisions. Weekly visits for wound
monitoring, including measurements and care, are
needed. After a bed of clean and pink granulation
is cultivated and there is measurable contraction,
patients return in a month after thigh lift. If  the
results are satisfactory, then 4-month intervals
suffice. Residual excess skin or adiposity and con-
tour irregularities may be addressed as soon as
6 months after thighplasty. While reasonably tight
 References 245

Figure 27.9  Frontal and right side views 18 months after her lower body and thigh surgery. The bikini
tan lines reflect her comfort with her new body shape.

immediately, unacceptable upper inner thigh skin REFERENCES

redundancy is the most common indication for
minor revision surgery, which is generally per-
formed at minimal operating room fees. Routine
follow-up is annual (Figure 27.9).
CPT CODING
15832 Excision, excessive skin and subcutaneous
tissue (includes lipectomy); thigh
1. Lockwood TE. Fascial anchoring technique
in medial thigh lifts Plast Reconstr Surg.
1988; 82:299–304.
2. Agha-Mohammadi S, Hurwitz DJ. Spiral
thigh lift. In: Strauch B, Herman CK, eds.
Encyclopedia of Body Sculpting after
Massive Weight Loss. New York, NY: Thieme
Medical; 2011: 243–250.
 28
Liposuction

ALAN MATARASSO AND RYAN M. NEINSTEIN

Introduction 247 Preoperative markings 251

Indications 248 Intraoperative details 252
Wetting solutions 249 Assessing regularity 254
Technology 249 Creating evenness 254
Anesthesia 250 Postoperative details 255
Fluid management in liposuction 250 Notes 255
Blood loss 251 Conclusion 256
Autologous fat transfer 251 CPT coding 256
Complications 251 References 256

Table 28.1  Special equipment

MicroAire® (Colson Associates, Chicago, IL) power-assisted
liposuction electric handpiece, base, and aspiration tubing
Niagara irrigation® (Acmi Corporation, Southborough, MA)
2-L pump (Figure 28.1)
MicroAire Mercedes tip liposuction cannulas, 1.8–6 mm
(Figure 28.2)
TED (thromboembolic deterrent) stockings and SCD
(sequential compression device)
Disposable #15 blade
5-0 nylon on a P-3 needle
Sterile antiseptic skin preparation
Forced air warmer
Tips/Pearls:
1. Penrose drains can be used to attach the suction
tubing to the power handpiece
2. Extra gowns/drapes if planning on changing patient
from prone to supine should be readily available

INTRODUCTION in the most commonly p ­ erformed cosmetic opera-

tions in the United States. From 2010 to 2011,
Liposuction was introduced by Illouz and o ­ thers to there was almost a 13% increase in the total num-
the plastic surgery community more than 30 years ber of liposuction ­procedures,  with  over  300,000
ago.1 Since its inception, it has c­ onsistently ranked

247
248 Liposuction
Figure 28.1  Niagara® High-Volume Irrigation Pump (Gyrus Acmi) 2-L pump.
Figure 28.2  Cannula and tray setup for body liposuction (PAL is not used for facial liposuction).
procedures  performed.2 One of the driving forces
behind the ­popularity of liposuction is the almost
universal demand that patients have for a thin-
ner, more attractive and symmetric appearance,
which is not always achievable with diet and exer-
cise. Furthermore, it has an e­ xcellent safety record,3
and the ­majority of patients are s­ atisfied with their
results.4 The  effects of ­ liposuction can motivate
patients to live a healthier lifestyle, although this may
not be a primary ­consideration in patient selection
or in their motivation for undergoing surgery. Table
28.1 provides a list of special equipment needed.
INDICATIONS
In general, potential candidates for liposuction
should  be healthy individuals close to their ideal
body weight with localized areas of lipodystrophy.
Females typically seek contouring of the abdo-
men, waist, outer and inner thighs, arms, along
with calves and ankles. In males it is the abdomen,
waist, chest, and neck that are sought-after areas.
Furthermore, patients who endeavor to improve
their appearance through diet, exercise, and a
healthy lifestyle are more likely to be satisfied with
their long-term postoperative results as described
by Rohrich et al.4 Realistic expectations and appro-
priate medical clearance are essential in minimiz-
ing complications and adverse outcomes.
Contraindications to liposuction include
patients who are medically or psychologically unfit
to withstand the surgery or recovery and patients
with unrealistic expectations. As well, there are

Table 28.2  Surgical indications for suction-assisted liposuction (SAL)
Aesthetic indications for SAL
Localized nonvisceral lipodystrophy
Generalized nonvisceral lipodstrophy
Good skin tone
Minimal to no striae
Realistic expectations
BMI <30
Nonsmoker
No medical comorbidities precluding surgery
certain areas of the body that are densely adherent
to the underlying tissues with little subcutaneous
fat, known as zones of adherence. These are areas
less amenable to contouring with liposuction and
are at high risk for irregularities. They include the
gluteal crease, lateral gluteal depression, middle
medial thigh, inferolateral iliotibial tract, and dis-
tal posterior thigh.5 Table  28.2 provides a list of
surgical indications for suction-assisted liposuc-
tion (SAL).6,7
WETTING SOLUTIONS
Liposuction techniques have evolved, and in par-
ticular, the injection of different forms of dilute
lidocaine- and epinephrine-containing solutions
prior to liposuction. Liposuction began with a dry
technique (no injection prior to liposuction) and
progressed to wet, superwet, and tumescent tech-
niques introduced in 1986 and later popularized
by Klein and others.8 The use of wetting solutions
containing large volumes of dilute local anes-
thetic with epinephrine has significantly enhanced
the effectiveness and safety of the procedure.9–11
Numerous reports have examined the metabo-
lism, safe dosages, and effectiveness of a range of
lidocaine doses and the metabolism of lidocaine in
liposuction.12 “True” tumescent anesthesia is con-
sidered a 3:1 infiltrate to aspirate under pure local
anesthesia. Most plastic surgeons report using
a wetting solution that is a variation of superwet
anesthesia. Superwet anesthesia uses 0.5 to 1.5 mL
Technology 249
Nonaesthetic indications for SAL
Lipoma/lipomatosis
Flap undermining
Flap defatting
Gynecomastia
Pseudogynecomastia
Breast reduction as an adjunct or sole modality
Buffalo hump
Hypertrophic insulin lipodystrophy
Lymphedema
Evacuating hematomas
Evacuating ruptured silicone implants
Emergency neck defatting for airway restoration
Axillary hyperhidrosis
Charcot-Marie-Tooth disease
of wetting solution per milliliter of aspirate along
with some type of systemic anesthesia. Tissue
blanching and moderate tension are considered
clinical endpoints of infiltrate.13 Superwet anesthe-
sia has many similar advantages to tumescent lipo-
suction. These advantages include large volumes
of fat may be removed, analgesia, and hydration,
all while using lower doses of lidocaine than tradi-
tional solutions.14 One new evolution in liposuction
technique is SAFE™ liposuction. Suction, aspira-
tion of fat, and equalization of fat is an evolving
technique using basic liposuction instrumentation
and wetting solutions to minimize contour irregu-
larities in both primary and secondary cases.15
TECHNOLOGY
Recently, there has been a renewed interest in the
different technologies in liposuction available to
the surgeon. The majority of procedures are per-
formed with traditional suction-assisted liposuc-
tion (SAL) or power-assisted liposuction (PAL)16;
however, other devices are available including
laser, ultrasound, radiofrequency, and water
assisted devices. The senior author prefers PAL.
PAL is a commonly used technology that uses a
variable-speed motor to provide reciprocating
motion to the cannula, which in combination with
the reciprocating action of the surgeon’s arm facil-
itates removal of adipose ­tissue.17 The principal
advantage of PAL is treatment speed and economy
of motion.
250 Liposuction
Vibration amplification of sound energy at
resonance (Vaser®; Sound Surgical Technologies,
Louisville, CO) is another modality that was intro-
duced to the United States with great fanfare after
early utilization with mixed results of hollow-
probe ultrasonic liposuction in the 1990s.5 Nagy
and Vanek18 compared Vaser-assisted lipoplasty
and SAL. They evaluated two objective end points:
skin retraction, in which Vaser showed a 6%
increase, and blood loss, which also showed a min-
imal benefit of 3 mL per 100 mL of aspirate. Both
surgeons and patients were unable to tell the differ-
ence between sides treated with either system.19-21
Laser-assisted liposuction is another system
designed to achieve traditional adipocyte removal
with fat-specific energy wavelengths along with
skin tightening from the thermal effect of the
laser in the dermis. Laser liposuction is the most
recent variation in the many concepts that began
with subdermal liposuction (or superficial), which
had the common hope to simultaneously aspi-
rate fat and tighten skin. It has been reported that
the laser provides a photothermic effect on the
fat, which translates into ease of instrument pas-
sage within the subcutaneous fat space and skin
thickening ­postoperatively.22 DiBernardo, in an
industry-funded study, treated 10 patients with
laser-assisted liposuction on half of the abdomen
and SAL on the other. A  statistically significant
effect on skin shrinkage and tightening with the
laser23 was reported.
The actual benefit of laser-assisted liposuction
and other modalities such as PAL or ultrasound
may be increased ease of cannula passage.24,25
Clinically meaningful and reproducible skin tight-
ening, which is the Holy Grail of what these dif-
ferent technologies are striving for, has still not
been reliably and regularly attained. Preliminary
clinical results of radiofrequency-assisted liposuc-
tion demonstrate rapid pre-aspiration liquefaction
of adipose tissue, coagulation of subcutaneous
blood vessels, and uniform sustained heating of
tissue.26 However, further research is required to
validate the results clinically. Recently, with efforts
attempting to improve fat-harvesting techniques
for autologous fat grafting, water-assisted lipo-
suction (WAL) has been proposed. It uses a fan-
shaped jet of tumescent solution to anesthetize
fat for liposuction and grafting, which may obvi-
ate the need for washing or centrifugation.27 More
research into these modalities is required to assist
surgeons in making decisions about which energy
device is appropriate for their practice.
ANESTHESIA
Anesthesia in liposuction procedures varies widely
among surgeons. Anesthesia technique should
reflect patient comorbidities, anatomic areas being
treated, length of procedure, volume of aspirate
planned, along with patient and surgeon ­preference.
Certain anesthetic, location, and operating param-
eters are important for liposuction. Wetting fluids
can be warmed to room temperature (with negligi-
ble benefits) and the patient maintained at normo-
thermic temperatures by warming the operating
room temperature and the use of intraoperative
warming blankets to decrease postoperative com-
plications associated with hypothermia, such as
infection and venous thromboembolism (VTE).28
Operating time should be minimized as VTE risk
increases with length of general anesthesia, along
with other factors.29 With anticipated small-vol-
ume liposuction, some surgeons prefer to perform
these procedures in an office-based setting with
various forms of anesthesia monitoring. A consen-
sus statement on large-volume liposuction (defined
as greater than 5 L total aspirate) regardless of
type of aspiration concludes that these procedures
should be performed in an acute-care hospital or
in an accredited facility with appropriate postop-
erative monitoring.30,31
FLUID MANAGEMENT IN
LIPOSUCTION
Under- or over- fluid resuscitation remains a criti-
cal issue with regard to liposuction.32 Empiric for-
mulas have been suggested. Rohrich et al. suggest
intraoperative fluid ratios near 1.8 for small-vol-
ume reductions and 1.2 for large-volume aspira-
tions.33 The intraoperative fluid ratio is defined as
the volume of intraoperative intravenous fluid
plus superwet solution divided by the aspiration
volume. For example, if a patient had a 1000-mL
lipoaspirate and had 1000 mL of superwet solu-
tion infiltrated, the patient should receive 800 mL
of intraoperative intravenous fluid. Pitman et al.
recommend that the total volume of fluid admin-
istered should equal twice the volume of total aspi-
rate.34 The senior author recommends the total
intake of injected, intravenous, and postoperative

fluid is 2 to 3 mL/mL aspirate over the course of the
two days after surgery.13
Our experience has shown that approximately
80% of the infiltrate is absorbed by hypodermoc-
lysis, leaving about 1:1 fluid absorbed to fat aspi-
rate. Consequently, over the next 24 hours the
patient requires fluid in the form of intravenous
and oral liquids to achieve a 2:1 ratio to the aspi-
rate.13 Whichever formula the surgeon chooses, it
is imperative to have open communication with
the anesthesiologist and recovery room personnel
and a thorough understanding of fluid dynamics
and physiology.
BLOOD LOSS
Blood loss after liposuction is not necessarily triv-
ial. Traditional teaching was that 1% of the aspirate
was blood, so a 2000-mL aspirate would only have
20 mL of blood. However, using the infranatant
solution as the only source of blood loss, the sur-
geon will likely underestimate the true extent of
blood loss. Swanson’s research has shown that up
to 98% of the blood loss from liposuction is from
third-space loss into the interstitial space.12 This
correlates to an approximate two-point drop in
hemoglobin for every 2500 mL of aspirate.35
AUTOLOGOUS FAT TRANSFER
Fat transfer remains controversial despite numer-
ous investigations over the last 25 years.36 Clinical
success is dependent on a number of variables.
There are a number of different techniques, all
encompassing some form of fat harvesting,37 pro-
cessing, treatment, and injection.38 The potential
to extract adipose-derived stem cells is promis-
ing and ultimately has plastic surgeons on the
forefront of regenerative medicine. This could be
considered similar to the contributions plastic sur-
geon Dr. Joseph Murray made to solid organ trans-
plantation. Proposed advantages of these stem cells
include the ability to continue to proliferate after
transplantation, the ability to promote neovascu-
larization, and their multipotent differentiation
capacity.39,40
In a position paper by the American Society
for Aesthetic Plastic Surgery (ASAPS) and the
American Society of Plastic Surgeons (ASPS) on
stem cells, it was determined that marketing and
promotion of stem cell procedures in aesthetic
Preoperative markings  251
surgery is not adequately supported by clinical
evidence at this time. Also, terms such as stem cell
therapy or stem cell procedure should be reserved to
describe those treatments or techniques by which
the collection, concentration, manipulation, and
therapeutic action of the stem cells is the primary
goal, rather than a passive result, of the treatment.41
COMPLICATIONS
As with any procedure, surgeons should be famil-
iar with all risks and possible complications. Most
complications in liposuction are minor in nature
and tend to resolve spontaneously. These include
skin irregularities, divots, hyperpigmentation,
asymmetry, and port site numbness. Rarely, cata-
strophic injuries such as internal organ perforations
are reported.42-44 Surgeons must be mindful of such
important entities as VTE and fat embolism syn-
drome. Miszkiewicz et al. published a systematic
review in 2008 that captured 11 articles and reported
rates of between 0% and 0.59% for deep vein throm-
bosis (DVT) in patients undergoing liposuction.45
PREOPERATIVE MARKINGS
(FIGURES 28.3 THROUGH 28.8)
1. In a warm, comfortable environment with the
patient in the standing position.
2. Liposuction areas are marked in conjunction
with the patient.
3. Typically multiple ports are used per area. This
allows for crisscrossing of targeted areas. Ports
can also be used for multiple areas.
4. Areas of contour irregularity or those sites
requiring autologous fat transfer are demarcated.
Figure 28.3  Typical markings for abdomen and
flanks liposuction. X indicates access incisions.
252 Liposuction
Figure 28.4  Typical markings for arm liposuction.
X indicates access incisions. The forearm would
be sterilely draped out of the surgical field.
Figure 28.5  Typical markings for back rolls and
flanks liposuction. X indicates access incisions.
Entry points are determined according to patient
preferences and ergonomics of liposuction.
INTRAOPERATIVE DETAILS
1. Systemic anesthesia is administered by an
anesthesiologist in conjunction with the infil-
tration of superwet infiltrate. DVT prophylaxis
includes placement of stockings in the hold-
ing area, initiation of sequential compression
devices prior to induction of anesthesia, and
early postoperative ambulation, all the while
preventing hypothermia.
2. Intraoperative steroids are given. First-
generation cephalosporin, or clindamycin if
Figure 28.6  Typical markings for lateral thigh and
flanks liposuction.
Figure 28.7  Typical markings for neck liposuc-
tion. Access points are submental and at the
insertion of the lobule. Alternatively, postau-
ricular incisions can be used. The body of the
mandible and the level of the hyoid are marked.
Jowl liposuction can be performed (circle).
a true penicillin allergy exists, is administered
perioperatively.
3. Stab wounds (disposable #15 blade) for intro-
ducing wetting solutions are injected with
1% lidocaine and epinephrine 1:1000.
4. Wetting solution is sequentially infiltrated
into the deep subcutaneous tissue until
 Intraoperative details  253

tissue ­blanching and moderate tension

using s­ uperwet a­ nesthesia (1 L Ringer’s
lactate, 20 mL 1% lidocaine, and 1 mL 1:1000
epinephrine).
5. Injection is done with a 14- to 16-gauge multi-
port reusable blunt cannula at a rapid infusion
rate of 200 to 300 mL/min.
6. Prepping and draping are done at the same
time as the surgeon scrubs; this allows for
diffusion of the wetting solution and for
the ­epinephrine to take effect.
7. After a surgical time-out, a variety of blunt
Mercedes cannulas in the 1.8- to 5-mm range
are used with PAL. The end point of suction
includes visual inspection, palpation, and
increase in blood in the aspirate. The senior
author uses a continuous motion with an out-
stretched hand on the wet skin (Figure 28.9),
moving in the deep plane along the fascia,
making sure not to stop at any point, which
could cause irregularities. The cannula is
brought up to the incision to change the suc-
tion direction.
8. All ports are closed with 5-0 nylon simple
interrupted sutures. Absorbable sutures,
staples, and secondary intention can also be
Figure 28.8  Typical markings for medial thigh used.
and knee liposuction. The mid-thigh access inci-
sion allows for knee and thigh procedures to be
done with the patient supine. A third popliteal
crease incision can be added.

Figure 28.9  Intraoperative use of PAL.

254 Liposuction

Tips/Pearls: Intraoperative techniques used in Creating evenness

PAL liposuction by the senior author
Typically, multiple ports are used to allow for
So as not to impede hemostasis by electrocau-
crosshatching of liposuction areas. When an
tery along with dissection the senior author
irregularity has been found, there are a num-
will reduce (typically less than 1 L) the amount
ber of techniques that may correct the problem.
of infiltrate used while performing liposuction
Manual fat separation with a “squeeze-and-
in conjunction with abdominoplasty. This also
push” technique can facilitate distribution of fat
allows for local anesthetic to be used for any
when aggressive force is used.48 SAFE liposuc-
adjacent areas of liposuction without exceed-
tion techniques of separation and equalization
ing safe lidocaine thresholds.
may reduce the requirement for these backup
techniques.15 “Cigar  rolling” (Figure  28.11) is a
Assessing regularity method in which the surgeon holds the skin and
fat tightly in one hand while performing liposuc-
Betadine® (Purdue Products, Stamford, CT) tion with the other; this ensures the proper plane
solution can be added to the field, and skin light of liposuction.
reflections can be assessed with the “panel beater”
method (Figure 28.10).46,47

Figure 28.10  Intraoperative demonstration of the “panel beater” method, after Toledo.

Figure 28.11  Intraoperative demonstration of “cigar rolling.”


Tips/Pearls: Liposuction
1.
Prior to intubation the patient can be
circumferentially prepped in the standing
position. The senior author prefers warmed
betadine for patient comfort. Patient is
intubated in the supine position, then the
abdomen is infiltrated along with flanks
or any proposed sites; the patient is then
turned to the prone position and injection
continues.
2.
Infiltration is performed off the field
with sterile gloves, local anesthetic, and
Betadine prep at the cannula insertion
site.
3.
A stab wound incision with a #15 blade is
made for the entry site.
4.
We prefer supine and prone positions to
adequately address flanks, hips, and medial
thighs as opposed to supine-lateral decubi-
tus procedures.
5.
The patient should be hyperextended
when performing liposuction on the
abdominal wall to reduce the risk of
visceral perforation from the injection
needles or cannulas. Infiltration and
liposuction should always be performed
tangentially to the plane of the abdo-
men. Extra care should be taken around
umbilical hernias, mesh, or ports from
weight loss surgery.
Medical Clearance Tips/Pearls: Preparation
for surgery
1.
Patients are offered hematology referrals to
screen for prothrombogenic factors that, if
positive, significantly increase the risk of
thromboembolism.
2.
Patients are to wash the liposuction area
as well as the area above and below with a
Betadine scrub beginning the night before
surgery and continuing on the morning of
surgery.
3.
Patients are to place Bactroban
(­mupirocin) into nares on the day of
surgery to limit possible methicillin-­
resistant Staphylococcus aureus (MRSA)
­exposure and related surgical site
infections.49
Notes 255
4.
Patients are asked to avoid all thrombo-
genic and anticoagulant medications and
herbal products 2 weeks before and after
surgery. They are advised to discontinue all
hormones as well.
POSTOPERATIVE DETAILS
1. After reversal of anesthesia the patient is sent
to the recovery room.
2. Patient is placed in snug-fitting elastic com-
pression garment postoperatively. The general
rule of thumb is that if a garment is used,
the patient should wear it for one week for
every decade of the patient’s age (e.g., 3 weeks
for a 30 year old).
3. If the patient has poor skin tone, Reston™
(3M, St. Paul, MN) foam or reinforced com-
pression (towel between the garment and skin)
can be used.
4. Patients are observed in the recovery room
until their conditions are stable for discharge.
Fluid status is frequently assessed by the surgi-
cal team in coordination with the anesthesiolo-
gist and recovery room personnel.
5. Small-volume cases are discharged home;
large-volume cases are admitted with or with-
out a Foley catheter to a monitored setting.
6. Follow-up with the patient is encouraged that
evening, the next day, and as required.
7. Lymphatic massage, ultrasound treatments,
and endermologie treatments can be offered to
reduce swelling.
NOTES
The surgeon needs to be aware of the exact amount
of local anesthetic and epinephrine infiltrated to
the patient and have a plan for fluid replacement.
Epinephrine is added to wetting solutions for its
vasoconstrictive and hemostatic effect.46 It allows
for higher doses of lidocaine by limiting absorp-
tion while prolonging its effect.10 Most surgeons
use concentrations50 of approximately 1:1,000,000.
Swanson12 showed that with a 1:500,000 concen-
tration and doses up to 10 mg total that there were
no adverse effects of the epinephrine in his wetting
solution. Pharmacokinetics show that exogenous
epinephrine levels peak at 2 hours 48 minutes
(range 1 to 4 hours) and approximately 25% to
256 Liposuction
32% of infiltrated epinephrine is absorbed.46 The
maximum safe dose of epinephrine is less than
0.7 mg/kg.42 Brown et al.46 showed no definitive
toxic effects in liposuction patients even though
the threshold for cardiac effects (100 pg/mL50) was
exceeded in all patients. Lidocaine may reach anti-
arrhythmic levels after liposuction and may pro-
tect the myocardium from epinephrine.12
Lidocaine in the wetting solution for liposuc-
tion has been extensively studied. Concentrations
of 35 mg/kg and up to 55 mg/kg have been safely
used, corresponding to (plasma) serum levels of
0.9 to 3.6 µg/mL, which peaks 8 to 14 hours after
­surgery.10,51,52 Lidocaine toxicity is manifested
early with central nervous dysfunction, such as
peri-oral numbness or tinnitus, eventually leading
to seizure and cardiovascular collapse. Treatment
includes prompt diagnosis, stopping the agent,
decreasing seizure threshold with diazepam, and
transfer to an appropriately monitored setting.
Despite bupivacaine’s widespread use in plastic
surgery, there have been concerns about its safety
with ­liposuction.53 Concerns are focused on the
cardiotoxicity of bupivacaine and its question-
able reversibility.54 Recently, Swanson12 showed
no complications from bupivacaine at doses of
550 mg when used during lipoabdominoplasty.
Recommended maximum doses are 225 mg in one
injection or 400 mg in 24 hours.55
CONCLUSION
Liposuction has vastly expanded the field of body
contouring for plastic surgeons. Unless evolution-
ary biology leads to dramatic changes in society’s
views on diet, exercise, and body image, the role of
body contouring will continue to grow.
Adipocyte-derived stem cell therapeutics, which
is an offshoot of liposuction, is an exciting field
within plastic surgery which is in its infancy.
Multiple energy platforms along with new tech-
niques are becoming available to the surgeon for
liposuction. However, it is imperative that regardless
of what platform is chosen, one should be aware of the
aesthetic goals of the procedure as well as being thor-
oughly familiar with the ­pharmacokinetics of local
anesthetics and ­epinephrine. Continual awareness
of the fluid shifts, blood loss, and fluid replacement
­strategies are essential to maintain safe homeostasis.
Finally, a patented injectable formulation of
deoxycholic acid has received FDA approval for
submental lipolysis. (http://www.kythera.com/
kythera-biopharmaceuticals-announces-fda-advi-
sory-committee-unanimously-17-0-recommends-
to-approve-atx-101-deoxycholic-acid-injection-to-
improve-the-appearance-of-moderate-to-severe-
submental-full/).
CPT CODING
When used for reconstructive purposes, the fol-
lowing CPT codes may be applicable.
15876 Head and neck
15877 Trunk
15878 Upper extremity
15879 Lower extremity
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 5
Part    

Hand

29 Carpal tunnel release: Open 261

Ali M. Soltani, Jose A. Baez, and Zubin J. Panthaki
30 Endoscopic carpal tunnel release: Anterograde single incision 265
Ari S. Hoschander, Matthew Mendez-Zfass, and Patrick Owens
31 Open trigger finger release for stenosing tenosynovitis 271
Benjamin J. Cousins and Haaris S. Mir
32 Surgical approaches to the hand and wrist 275
Ross Wodicka and Morad Askari
 29
Carpal tunnel release: Open

ALI M. SOLTANI, JOSE A. BAEZ, AND ZUBIN J. PANTHAKI

Introduction 262 Position 263

Surgical preparation 262 Procedure 263
Preoperative markings 262 Postoperative details 264
Anesthesia 262 CPT coding 264
Intraoperative details 263 Suggested readings 264

INDICATIONS

1. Numbness in the median nerve distribution 3. Positive results on electromyographic (EMG)

2. Positive Tinel sign, positive Durkan test, testing and nerve conduction velocity testing
decreased two-point discrimination (both (increased median motor latency)
moving and static)

Table 29.1  Special equipment

Sterile skin marker
Raytech sponges
Esmarch bandage
#15 scalpel
Senn retractors (2)
Freer elevator
Ragnell retractors (2)
Adson forceps (2)
Mayo straight scissors
Webster needle driver
4-0 nylon suture
Xeroform 1 × 8 strip
Kerlix wrap (4”)
Gauze sponges, sterile (4 × 4)
Ace wrap (4”)

261
262  Carpal tunnel release: Open
INTRODUCTION
Carpal tunnel release surgery is one of the most
gratifying and satisfactory surgeries done by the
hand surgeon. It can provide immediate and lasting
relief to patients suffering from pain and disability.
Carpal tunnel release surgery has progressed
from very extensive surgeries to short-scar open
surgeries and endoscopic approaches. The option
chosen is often up to surgeon preference and
patient preference, but there are some indications
when it is preferable to choose the open approach.
Table  29.1 indicates equipment necessary for the
procedure. Surgical equipment required in the
operating room includes hand surgery table, sit-
ting stools, sterile gloves, sterile drapes, surgical
tourniquet with padding and 1010 drape, prep
solution (Figure 29.1).
Figure 29.1  Tray of necessary instruments.
Figure 29.2  Skin markings.
SURGICAL PREPARATION
Peri-operative antibiotics are provided prior to
inflation of the tourniquet.
PREOPERATIVE MARKINGS
Surgical marking is made vertically in mid-palm
from Kaplan line to 0.5 cm distal to the wrist
crease. The Kaplan line is an imaginary oblique
line extending from the first web space to 0.5 cm
distal to the pisiform (Figure 29.2).
ANESTHESIA
A local anesthetic mixture of lidocaine 1% with
epinephrine 1:100,000 (4.5 mL), bupivicaine
­
0.25% (4.5 mL), and sodium bicarbonate (1 mL)
 Intraoperative details  263

is prepared. 10 mL of this mixture is then injected and distally until the carpal tunnel is completely
into the subcutaneous tissue of the palm and released (Figure 29.4).
­d istal  forearm. The surgery may be performed Once the carpal tunnel is completely released,
under local anesthesia or local anesthesia with we ensure meticulous hemostasis using bipolar
mild ­sedation. It is not necessary to use general electrocautery. We verify visually that the car-
­a nesthesia with this operation. pal tunnel contents are undamaged by our sur-
gical dissection; then we proceed to close the
INTRAOPERATIVE DETAILS skin using 4-0 nylon horizontal mattress sutures
(Figure 29.5).
Position The wounds are dressed with Xeroform fol-
lowed by fluff gauze in the web spaces. Then a
Supine, patient with the right arm abducted 4-inch Kerlix™ (Covidien, Dublin, Ireland) wrap
90 degrees on an arm board. and a 4-inch Ace™ (3M, St. Paul, MN) wrap are
applied. Total tourniquet time is generally approx-
Procedure imately 7 minutes.
When the tourniquet is released, the hand
After adequate prep and drape, a time-out is ­surgeon verifies that the hand, fingers, and thumb
­performed. The surgical site, antibiotic, surgeon, all pink up nicely and rapidly.
and procedure are all verified. Following  this,
the right upper extremity is exsanguinated with an
Esmarch bandage and the tourniquet is inflated to
250 mmHg pressure.
Next, the surgeon makes a short scar open car-
pal tunnel release incision as per the preoperative
markings. We dissect down using two Senn retrac-
tors for soft tissue distraction and a #15  scalpel
blade to cut through the skin, subcutaneous t­ issues,
and the palmar fascia and down to the transverse
carpal ligament (Figure  29.3). We expose the
­transverse carpal ligament throughout its length.
We then incise the transverse carpal l­igament in
one location in a longitudinal orientation and then
use a Freer elevator to protect the carpal tunnel
contents while we extend the incision proximally Figure 29.4  Incision through the transverse
­carpal ligament.

Figure 29.3  Exposure of the transverse carpal

ligament. Figure 29.5  Final skin closure.
264  Carpal tunnel release: Open
POSTOPERATIVE DETAILS
The patient will keep the arm elevated and the
dressing dry and intact for 10 to 14 days post-
operatively. The sutures should be removed
between 10 and 14 days postoperatively. Steri-
Strips™ (3M) can be applied. Patient may start
gentle active range of motion when dressing and
sutures are removed. About half of the patients
after surgery will benefit from occupational ther-
apy for edema r­eduction, range of motion, and
­strengthening. Scar m­ assage is also instituted.
We advise patients that ­symptoms of burning
and pain generally resolve soon after surgery.
Symptoms associated with ­numbness may take
much longer to resolve—up to one year. Thenar
atrophy may never be resolved if it has been long-
standing. Some patients may occasionally suffer
from pillar pain, which is pain on the sides of the
scar. This is treated with therapy and massage
and can last for up to one year.
CPT CODING
64721 Carpal tunnel operation
SUGGESTED READINGS
Plast Reconstr Surg. 2008 Apr;121(4 Suppl):1–10.
Plast Reconstr Surg. 2013 Jul;132(1):114–21.
 30
Endoscopic carpal tunnel release:
Anterograde single incision*

ARI S. HOSCHANDER, MATTHEW MENDEZ-ZFASS, AND PATRICK OWENS

Introduction 265 Postoperative protocol 268

Anesthesia 266 Notes 268
Markings 266 CPT coding 268
Operative procedure 266 Suggested readings 268

INDICATIONS

Uncomplicated carpal tunnel syndrome: diagnosed by positive physical examination findings,

­electromyogram (EMG), or both, demonstrating median nerve compression at the carpal tunnel.

Table 30.1  Special equipment

Standard hand table and drapes 18- or 24-inch tourniquet and Esmarch
#15 scalpel Synovial elevator
Progressive blunt dilators 3M Agee Carpal Tunnel Release System
5-0 nylon suture Petrolatum gauze dressing
4 × 4 inch gauze 3-inch elastic bandage wrap

INTRODUCTION made, including, but not limited to, cervical radicu-

Endoscopic carpal tunnel release using an antero-
grade portal is a safe and effective means of releasing
median nerve compression at the carpal tunnel for
patients with symptomatic median nerve compres-
sion. In the early stages of median nerve compres-
sion, patients will typically complain of numbness,
pain, and paresthesias in the thumb, index, and long
fingers. However, the paresthesias may be described
beginning as high as the neck and elbow. All other
pathology must be ruled out before the diagnosis is
* Endoscopic Carpal Tunnel Release video is available at http://goo.gl/4Uab7r
lopathy and compression at the elbow. Physical exam
findings will typically demonstrate a positive Phalen
and Durkan tests in the early stages and, in the
later stages, weakness and thenar muscle wasting.
Electromyographic (EMG) and nerve conduction
studies (NCS) of the ulnar and median nerves at the
elbow and the wrist are commonly performed prior
to surgery. These tests can define the site of com-
pression and quantify the pathology. Non-operative
treatments include bracing and steroid injections.
Table 30.1 indicates the necessary equipment.

265
266  Endoscopic carpal tunnel release: Anterograde single incision

ANESTHESIA 4. A synovial elevator is then used, pointed

High wrist block or axillary block.
MARKINGS
After appropriately marking the patient’s correct arm
(Figure 30.1), the procedure begins with a mark on
the patient’s forearm at 1 cm proximal to the distal
wrist flexion crease between the palmaris longus and
the radial border of the flexor carpi ulnaris. In addi-
tion, the pisiform and hook of the hamate should be
marked, and the distal end of the transverse carpal
ligament should be palpable. All instrumentation
should be aimed in the direction of the fourth ray.
upward; it is then inserted into the carpal
tunnel to release the synovium from the
underside of the transverse carpal ligament
(Figure 30.4).
5. Hamate dilators of increasing size (#1 then #2)
are used to dilate the tunnel (Figure 30.5).
6. The square dilator that is the same size,
length, and shape as the endoscope is used
to obtain a sense of the depth and direction
of the tunnel. The carpal tunnel is inclined
roughly 30° from the plane of the forearm
(Figure 30.6).

OPERATIVE PROCEDURE
1. The Esmarch bandage is used to exsan-
guinate the arm; the tourniquet is inflated
100 mmHg > systolic blood pressure.
2. A 1.5-cm transverse skin incision is made
(Figure 30.2).
3. Soft tissues are carefully dissected to the level
of the antebrachial fascia. Forceps with teeth
should be used to hold the fascia under ten-
sion to maintain the appropriate plane. It is
imperative that the forceps maintain the distal
aspect of the antebrachial fascia throughout
Figure 30.2  The incision is made through skin
this entire portion of the procedure until the
with a #15 blade.
endoscope is inserted (Figure 30.3).

Figure 30.1  A transverse mark 1 cm proximal to Figure 30.3  Careful dissection through the
the distal wrist flexion crease. The pisiform (large antebrachial fascia establishes the correct surgi-
circle) and hook of the hamate (small circle) are cal plane. This plane should be maintained at all
also seen. times with the Adison forcep.
 Operative procedure  267

Figure 30.6  The square dilator is inserted into

the carpal tunnel.

Figure 30.4  A synovial elevator is used to clear

synovium out of the tunnel.

Figure 30.7  The endoscope is inserted just under

the fascia.

9. We retract the device with the blade deployed

10. At this point, ensure that all of the distal fibers
Figure 30.5  Progressive dilation is performed
with blunt dilators in the direction and plane of
the carpal tunnel.
7. The Agee Carpal Tunnel Release System
(3M, St. Paul, MN) is inserted just under the
edge of the fascia into the carpal tunnel. It is
important that all of the synovium is removed
from the undersurface of the transverse
carpal ligament prior to deploying the blade
(Figure 30.7).
8. The palmar fat pad is identified, and the
blade is deployed at the level of the dis-
tal end of the transverse carpal ligament
(Figure 30.8).
approximately halfway across the transverse
carpal ligament.
have been cut; repeat this motion if they have
not been completely severed (Figure 30.9).
In this fashion, we do not have to re-approach
the distal segment after the entire ligament
has been released. This would prove to be
difficult with extremely poor visualization.
Now, we redeploy the blade and incise the
remainder of the ligament (Figure 30.10).
11. After the release is complete and visually
inspected, it is evaluated with the square
dilator to ensure adequate enlargement of
the carpal tunnel.
12. A single 5-0 nylon suture in horizontal mat-
tress fashion is used for closure.
13. The wound is covered with petrolatum gauze
and 4 × 4 gauze that spans the carpal tunnel
and it is wrapped with an Ace (3M) bandage.
14. The tourniquet is released.
268  Endoscopic carpal tunnel release: Anterograde single incision
Figure 30.8  The distal aspects of the tunnel and
fat pad are identified.
Figure 30.9  The distal fibers are released.
POSTOPERATIVE PROTOCOL
The bandage may be removed and covered with an
adhesive bandage in 2–3 days. Sutures are removed
at 7–10 days, and the patient may gradually increase
activity as tolerated.
NOTES
The procedure is safe and effective. The key is
visualization during all portions of deployment of
the endoscopic scalpel. This prevents injury to the
Figure 30.10  After releasing the remaining distal
fibers, the entire ligament is released.
motor recurrent branch of the median nerve. There
should be no hesitation to convert to the open ver-
sion of this procedure if visualization is less than
optimal.
CPT CODING
29848 Endoscopic carpal tunnel release
20526 Injection, therapeutic; carpal tunnel
SUGGESTED READINGS
Abrams R. Endoscopic versus open ­c arpal
tunnel release. J Hand Surg Am.
2009;34(3):535–539.
Beck JD, Deegan JH, Rhoades D, Klena JC.
Results of endoscopic carpal tunnel
release relative to surgeon experience
with the Agee technique. J Hand Surg Am.
2011;36(1):61–64.
Brown LG. Endoscopic compared with
open ­c arpal tunnel release. J Bone Joint
Surg Am. 2003;85-A(5):964; author
reply 964.
Cobb TK, Knudson GA, Cooney WP. The
use of topographical landmarks to
improve the outcome of Agee ­endoscopic
carpal ­tunnel release. Arthroscopy.
1995;11(2):165–172.

Macdermid JC, Richards RS, Roth JH, Ross DC,
King GJ. Endoscopic versus open carpal tun-
nel release: a randomized trial. J Hand Surg
Am. 2003;28(3):475–480.
Ruch DS, Poehling GG. Endoscopic carpal t­ unnel
release: the Agee technique. Hand Clin.
1996;12(2):299–303.
Suggested readings  269
Scholten RJ, Mink van der Molen A,
Uitdehaag BM, Bouter LM, de Vet HC.
Surgical treatment options for carpal tun-
nel syndrome. Cochrane Database Syst Rev.
2007;(4)(4):CD003905.
 31
Open trigger finger release for
stenosing tenosynovitis

BENJAMIN J. COUSINS AND HAARIS S. MIR

History 271 Anesthesia 272

Etiology 271 Operative procedure 272
Indications for surgery 272 Postoperative care 273
Surgical preparation 272 CPT coding 273
Surgical markings 272 Suggested readings 273

Table 31.1  Special equipment

Sterile skin marker
Raytech sponges
Esmarch bandage
#15 scalpel or Beaver blade scalpel
Senn retractors (2)
Ragnell retractors (2)
Adson forceps (2)
Mayo straight scissors
Webster needle driver
5-0 nylon suture
Xeroform, 1” × 3” strip
Gauze sponges, sterile, 4” × 4”
Ace wrap, 4”

HISTORY
The trigger finger was first described by Notta in
1850. The first release was performed by Schönborn
in 1889. Subsequently, the first annular (A1) pulley
release has been described via a transverse, longi-
tudinal, or chevron incision as well as percutane-
ous techniques.
ETIOLOGY
Triggering of digits occurs secondary to a dis-
proportion of the digital retinacular sheath and
contents (flexor tendon and synovial sheath).
“Bunching” of tendon fibers is caused by the
angular entry of the tendon against the digital

271
272  Open trigger finger release for stenosing tenosynovitis

retinacular sheath as they enter the A1 pulley; this

causes friction and trauma.

INDICATIONS FOR SURGERY

Failure of non-operative treatment, including
activity modification, splinting, non-steroidal
anti-inflammatory drugs (NSAIDs), and most
A2
commonly, corticosteroid injections. Patients
A1
may have painful or symptomatic catching,
sticking, or triggering of a finger when flexed
into the palm, often necessitating release with the
contralateral hand. Frequently, a painful mass
can be palpated in the palm just proximal to the
A1 pulley.
Release of the A1 pulley to relieve symp-
toms from stenosing tenosynovitis may be done
with needle release of the A1 pulley; some clini- Figure 31.1  Anatomic location of the A1 pulleys.
cians prefer this technique if triggering occurs on (Figure by Benjamin J. Cousins, MD.)
command. We prefer an open technique utiliz-
ing a small oblique skin incision, which requires
minimal anesthesia and has a short postoperative 2 . The incision will be an approximately 1-cm
recovery time. Operative equipment is given in angled incision. Incisions for each digit
Table 31.1. are as follows: Thumb, incision along the
thumb metacarpal phalangeal joint; index
SURGICAL PREPARATION finger, adjacent to the distal palmar crease;
long ­f inger, midway between the distal and
1. In the preoperative area, identify the correct proximal palmar crease; ring and small
patient, hand, and finger(s) to be released. fingers, adjacent to the distal palmar crease
Mark the digit or digits to be released with the (Figure 31.1).
identifying physician’s initials.
2. Apply cushioned cotton wrap and over this
apply an appropriate size upper arm tourniquet Anesthesia
to the side to be operated on. Apply a 10/10
The surgery may be performed under local
drape at the distal skin/tourniquet border.
anesthesia alone or local anesthesia with mild
3. Prep the hand, nails, and forearm with
sedation. It is not necessary to use general
a 5-minute scrub of 2% or 4% chlorhexi-
anesthesia with this operation. A mixture of
dine and apply sterile drapes without
anesthetic agents, such as lidocaine 1% with epi-
contamination.
nephrine and bupivicaine 0.25%, can be used as
4. Once prepped and draped, again re-identify
a digital block. For patients with multiple trigger
and confirm the correct patient, hand, and
fingers, a regional block may be better tolerated
finger(s) to be operated on and confirm with
by the patient.
other operating team and operating room staff
members.
OPERATIVE PROCEDURE
SURGICAL MARKINGS
1. Exsanguinate the hand and forearm with
1. Repeat identification of the correct hand, an Ace ™ (3M, St. Paul, MN) bandage or
patient, and finger(s) and ensure proper mark- Esmarch wrap and inflate the tourniquet to
ing preoperatively. 250 mmHg.
 Suggested readings  273

2 . With the correct finger identified and

appropriate retraction, make a 1-cm
­d iagonal skin incision beginning approxi-
mately 1 cm ­proximal to the palmer digi-
tal crease b ­ eginning. The incision should
begin ­radially and ­continue ulnarly and
lie in line with the digit/­tendon to be
released.
3. After incising the skin, blunt dissection with
tenotomy scissors is done. After a few spreads
longitudinally, the A1 pulley should be readily
visualized.
4 . Place Ragnall or blunt Senn retractors
in the radial and ulnar edges of the inci-
sion. An additional retractor can be placed
in the ­i nferior or superior edge for more
exposure. Figure 31.2  Exposure of A1 pulley to be incised.
5. Additional dissection with the tenotomy (Figure by Benjamin J. Cousins, MD.)
scissors is continued until the pulley is freely
2. The patient is instructed to begin moving their
exposed and visualized.
digits immediately postoperatively to avoid
6. The A2 pulley begins approximately 4 mm
stiffness.
proximal to the palmar digital crease and
3. The dressing is removed after 48 hours, and the
should not be cut.
sutures are removed at the first postoperative
7. With a #15 blade scalpel or Beaver shaped
visit.
knife blade, the A1 pulley is cut with gentle
knife pressure in a longitudinal, proximal-to-
distal direction. Avoid cutting the underlying CPT CODING
­tendons (Figure 31.2).
8. After release of the A1 pulley, be sure to 26055 Tendon sheath incision (e.g., for trigger
examine for cessation of triggering with gentle finger)
flexion and extension of the digits to ensure 26060 Tenotomy, percutaneous, single, each digit
adequate release and no additional catch
points.
9. Perform confirmatory Miami Testing. With
SUGGESTED READINGS
adequate exposure, observe the tendon excur- Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter
sion throughout its path proximally and JB, Mudgal CS, Ring DC, Adverse events
distally. Ensure that there is no “bunching” or of open A1 pulley release for idiopathic
wrinkling of the tendon throughout the course trigger finger. J Hand Surg Am. 2012
of its movement. With the tendon able to glide Aug;37(8):1650–1656.
freely and smoothly without hitches or stops, Mol MF, Neuhaus V, Becker SJ, Jupiter JB,
the release and operation are complete. Mudgal C, Ring D, Resolution and recur-
rence rates of idiopathic trigger finger after
corticosteroid injection. Hand (NY), 2013
POSTOPERATIVE CARE Jun;8(2):183–190.
Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH
1. A small strip of xeroform gauze is placed over (eds.), Chapter 62, in Green's Operative Hand
the closed skin incision and then covered with Surgery; 6th Ed., pp. 2071–2079, Churchill
sterile 4" × 4" gauze. The bandage is then cov- Livingstone, London.
ered with the Ace bandage wrapped snugly, but
not tightly.

Surgical approaches to the hand
and wrist
ROSS WODICKA AND MORAD ASKARI
Introduction 275
Guyon’s canal approach 275
Approach to the metacarpal bone 276
Dorsal approach to the wrist 276
Dorsal ulnar approach 277
Carpal tunnel approach 277
Volar approach to the scaphoid 278
INTRODUCTION
The intricate anatomy of the hand dictates the
use of specific incisions and approaches to expose
various areas or structures of the hand and wrist.
Each approach is aimed to minimize manipula-
tion or trauma to the surrounding structures and
to ­prevent the compromise of eventual function of
the hand while giving the surgeon adequate expo-
sure to the area of interest. Approaches to common
surgical problems in the hand are presented here.
GUYON’S CANAL APPROACH
Guyon’s canal is an enclosed fibro-osseous space
at the volar/ulnar base of the hand traversed by
the ulnar artery and nerve. Its borders include
the p
­ isiform (ulnar wall), the hook of the hamate
(radial wall), the volar carpal ligament (roof), and
the transverse carpal ligament (floor). The exposure
can be used to address fractures of the pisiform
and the hook of the hamate, as well as pisotriqu-
etral arthritis, or release of the ulnar nerve in ulnar
tunnel syndrome.
32
Volar approach to the distal radius 278
Approach to the basal joint of the thumb 279
Approach to the metacarpophalangeal and
interphalangeal joints and phalanges 279
Volar or mid-lateral approach to the fingers 280
References 280
Suggested reading 281
Prior to beginning the approach, it is important
to identify and mark the pisiform and the hook
of the hamate. The pisiform is found immediately
distal to the wrist flexion crease in line with the
flexor carpi ulnaris (FCU) tendon. The hook of the
hamate is located 2 cm distal and 2 cm radial to
the pisiform. Starting at the hook of the hamate, a
zigzag incision is extended proximally, just radial to
the pisiform. It is important not to cross the flexion
crease perpendicularly. Cutaneous branches of the
ulnar nerve run through the subcutaneous tissues
here, so careful subcutaneous dissection is impera-
tive. Proximally, the FCU tendon is identified and
mobilized. The ulnar nerve and artery are deep and
just radial to the tendon, with the nerve typically
superficial and ulnar to the artery. The neurovas-
cular bundle can be followed distally, deep to the
volar carpal ligament and palmaris brevis muscle,
which are both divided longitudinally. Advancing
deeper, the motor branch of the ulnar nerve dives
below a fibrous arch at the origin of the hypothenar
muscles. This branch runs adjacent to the hook of
the hamate on its way to innervate the interosse-
ous muscles. This branch must be protected during
275
276  Surgical approaches to the hand and wrist
excision of the hook of the hamate as it is dissected
away from surrounding soft tissue. As the neuro-
vascular bundle is released, it can be retracted to
give safe access to the pisiform and hamate.
APPROACH TO THE METACARPAL
BONE
Approach to the metacarpal bone is typically
achieved  with a dorsal longitudinal incision
either directly over the metacarpal shaft or in the
­intermetacarpal space if two metacarpal bones need
to be accessed. The location of the incision is centered
over the area of interest (e.g., in the case of shaft frac-
ture, over the midshaft of the metacarpal bone, while
for carpometacarpal [CMC] arthroplasty or arthro­
desis, it is placed more proximally) (see Figure 32.1).
Overlying extensor tendons must be identified and
protected when necessary. An attempt must be made
to also identify and protect small superficial dorsal
branches of the radial and ulnar nerves. The perios-
teum is then incised longitudinally along the length
of the metacarpal shaft, with care taken to preserve
the interosseous muscles on either side. Using a peri-
osteal elevator, the muscles along with the perios-
teum are mobilized to give access to the bone while
Figure 32.1  Approach to MCP and IP joint:
Incision is drawn on the dorsum of the MCP joint
or IP joint. The incision may be drawn curvilinear
to avoid placement of a scar on the most stretch-
able part of the skin over the joint.
avoiding circumferential stripping and keeping
exposure to a minimum.
DORSAL APPROACH TO THE WRIST
The dorsal midline approach to the wrist provides
excellent exposure to the carpal bones (except the
trapezium and pisiform), as well as the extensor
tendons at the level of the wrist, the second through
fifth CMC joints, and the triangular fibrocartilage.
It is the utilitarian approach to the dorsal wrist,
and its multiple uses include repair of extensor
tendons, wrist fusion, radial styloidectomy, repair
of the intercarpal ligament, perilunate dislocation,
open reduction internal fixation (ORIF) of the
­distal radius and carpal fractures, and proximal
row carpectomy, among others.1,2
A 6- to 8-cm mid-dorsal incision is centered over
the radiocarpal joint. To appropriately identify the
position of the radiocarpal joint, one should mark the
radial styloid and ulnar styloid, as well as the Lister
tubercle on the dorsum of the wrist (Figure  32.2).
The incision can be extended as needed. Care must
be taken distally to identify and avoid the superfi-
cial radial and ulnar dorsal nerves at the base of the
third metacarpal. Superficially, the subcutaneous fat
Figure 32.2  Mid-dorsal wrist approach: Incision
is centered over the radiocarpal joint and serves
as the workhorse incision for treatment of various
pathologies involving the distal radius and the
carpus.

is incised in line with the skin incision, revealing the
extensor reticulum. Incise the extensor retinaculum
over the third dorsal compartment and release the
extensor indicis proprius (EIP) tendon. The retinacu-
lum will be opened ulnarly by exposing the ­contents
of the fourth dorsal compartment.
Retracting these tendons radially and ulnarly
will expose the underlying dorsal radiocarpal
joint capsule and the dorsal radiocarpal ligaments.
The capsule can then be incised using an inverted
T-shaped incision (direct longitudinal approach)
or a ligament-sparing approach.3 If the approach
needs to be extended proximally, retinacular flaps
will be raised on the radial and ulnar sides to expose
the second through fifth dorsal compartments.
When the entire proximal row and ­midcarpal
row need to be accessed, a ligament-sparing
approach is best utilized. In this technique, a radi-
ally based dorsal capsular flap is raised by incising
along the fibers of the radio-triquetral ligament
and dorsal intercarpal ligaments and connecting
them over the dorsal horn of triquetrum.
DORSAL ULNAR APPROACH
This approach provides access to the dorsal ulnar
side of the wrist, including the ulnar carpal bones,
the TFCC, distal radioulnar joint, and the ulnar
head. Incision is placed over the fifth dorsal com-
partment. A similar mid-dorsal incision through
the skin can also be used. Incision is centered over
the area of interest. The extensor retinaculum is
incised over the fifth dorsal compartment. The
extensor digiti minimi (EDM) is mobilized and
retracted. The joint can then be exposed with care-
ful dissection with minimal dorsal capsulotomy,
avoiding the TFCC and dorsal radioulnar ligament.4
At risk in this approach is the dorsal sensory branch
of the ulnar nerve during subcutaneous dissection.5
CARPAL TUNNEL APPROACH
The carpal tunnel contains nine flexor tendons and
the median nerve. The borders of the carpal tunnel
are the transverse carpal ligament (roof), carpal
bones (floor), hook of the hamate (ulnar wall), and
the scaphoid (radial wall). The approach can be
used for open carpal tunnel release, perilunate dis-
locations, and fractures of the hook of the hamate.
The pisiform, hook of the hamate, and Kaplan car-
dinal line should be identified and marked. The line
Carpal tunnel approach  277
starts at the ulnar base of the abducted thumb and
runs parallel to the thumb. This line was shown by
Vella et al.6 to most consistently reproduce the loca-
tion of important deep structures, such as the recur-
rent motor branch of the median nerve and the
superficial palmar arch. The intersection of this line
and a longitudinal line drawn in line with the radial
border of the ring finger marks the distal aspect of
the incision. The incision is extended proximally as
necessary toward the wrist crease (Figure 32.3).
The incision is carried down through the subcu-
taneous fat. Deep to the fat lies the longitudinally
oriented fibers of the palmar fascia. These fascial
fibers as well as the palmaris brevis muscle fibers
are divided and swept, thus exposing the transverse
carpal ligament. The transverse carpal ligament
is then incised, with care taken to avoid injury to
the underlying median nerve and the recurrent
motor branch, which often crosses the field at this
level. The incision is carried distally until the volar
fat pad is encountered. This is a reliable anatomic
landmark marking the distal end of the carpal tun-
nel. Proximally, full release of the transverse carpal
ligament is confirmed visually, usually about 1 cm
proximal to the distal wrist crease. A retractor is
then used to bring the median nerve and flexor ten-
dons radially, exposing the floor of the canal and
releasing the proximal antebrachiocutaneous fascia.
Figure 32.3  Carpal tunnel approach: Incision is
parallel to the long axis of the ring finger and
extends proximally to the wrist crease.
278  Surgical approaches to the hand and wrist

VOLAR APPROACH TO THE distal radius. The radial artery is located between
SCAPHOID the two. The incision is made directly over or
slightly radial to the palpable FCR tendon on the
The scaphoid may have a volar or dorsal approach volar distal forearm (Figure  32.4). Depending on
based on the area of interest. The dorsal approach the location of the fracture, extension across the
is similar to the approach described for the dorsal wrist crease may be necessary. If this is the case,
wrist. The volar approach to the scaphoid is com-
monly used for ORIF of distal two-thirds scaphoid
fractures and non-unions. It is important to iden-
tify and protect the radial artery at all times during
this approach. Advantages over the dorsal approach
include the ability to correct the “humpback” defor-
mity characteristic of scaphoid nonunions, as well
as avoidance of the dorsal vasculature.7
The scaphoid tuberosity and the flexor carpi radi-
alis (FCR) tendon should be palpated and marked.
The incision runs in line with the FCR tendon,
extending 2 cm proximal and 1–2 cm distal to the
scaphoid tubercle. The distal aspect of the incision is
angled radially toward the base of the thumb. A zig-
zag incision may also be constructed using the same
landmarks. The superficial volar branch of the super-
ficial branch of the radial artery can be identified
and retracted or ligated as needed. The FCR sheath
is then opened, and the tendon is retracted ulnarly.
The floor of the FCR sheath and the joint capsule are
then incised longitudinally. The radioscaphocapitate
and the long radiolunate ligament will need to be
divided for exposure of the waist and proximal pole.
If access to the distal pole is required, the scaphotra-
pezial joint should be identified, the scaphotrapezial
ligament divided in line with its fibers, and the joint
capsule opened over the distal pole. Dissection of the
capsule should be kept to a minimum in an attempt
to preserve blood supply to the distal pole, and all
divided volar ligaments need to be repaired anatomi-
cally to contain the proximal pole and prevent volar
tilt of the scaphoid.

VOLAR APPROACH TO THE DISTAL

RADIUS
The volar approach to the distal radius is the work-
horse approach for distal radius fractures. The FCR
and brachioradialis are identified, as is the radial
artery. The FCR originates as part of the  com-
mon flexor wad on the medial epicondyle of the
humerus and inserts at the base of the second and
third metacarpals; the brachioradialis originates Figure 32.4  Volar approach to distal radius:
on the lateral supra-condylar ridge of the humerus Incision is designed over the distal portion of the
and inserts broadly on the radial border of the flexor carpi radialis.
 Approach to the metacarpophalangeal and interphalangeal joints and phalanges  279
the incision is curved radially to avoid crossing
perpendicular to the crease, as well as to stay clear
of the palmar cutaneous branch of median nerve.
Sharp dissection is taken down through the
skin and subcutaneous fat until the volar fibers of
the FCR tendon sheath are visible. The sheath is
incised, and the tendon is retracted ulnarly. Next,
the floor of the FCR sheath is incised. Directly
beneath the sheath is the muscle belly of the flexor
pollicis longus. The muscle is bluntly swept to the
side to expose deep fibers of the pronator qua-
dratus. The pronator is frequently disrupted or
completely detached by the fracture fragments in
high-impact fractures. Sharp dissection is used to
detach the pronator from the radial border of the
radius with an L-type incision. A small cuff of tis-
sue is left for later repair. Following elevation of the
muscle, the fracture should be in full view.
There are several key structures to be aware of
when making this approach. The palmar cutaneous
branch of the median nerve runs ulnar to the FCR and
arises 5 cm proximal to the wrist joint. Injury to the
nerve with careless dissection or retractor placement
can lead to a noticeable sensory deficit. The radial
artery is a concern on the radial side of the field and
should be identified and protected at all times during
the approach. It is advisable to use a blunt instrument
for retraction around the vessel. Also, the volar wrist
capsular ligaments must be preserved unless access
to the wrist joint is necessary. Errant release of these
ligaments will result in radiocarpal instability.
APPROACH TO THE BASAL JOINT
OF THE THUMB
The base of the thumb, specifically the first CMC
joint, is surgically accessed in cases of severe
arthritis requiring arthroplasty and ligament
reconstruction. Also, access is necessary in cases
of displaced intra-articular first CMC fracture
(Bennett/Rolando fractures).
Exposure can be achieved through a radiopal-
mar approach. A straight incision may be made
beginning at the thenar eminence at the junction
between the dorsal and palmar skin. The inci-
sion is taken distally about 4–5 cm. In the subcu-
taneous tissue lie divisions of the dorsal sensory
branch of the radial nerve.8 An attempt should be
made to preserve these branches. Blunt dissection
is taken down to the thenar musculature, which
is then elevated sharply off the metacarpal base.
These muscles are then retracted to the ulnar side,
­exposing the trapezium. At this point, the joint
can be visualized, and a longitudinal or horizon-
tal capsulotomy is performed. Alternatively, some
surgeons prefer a curved incision (Wagner) or a
triradiate incision. Also, a direct dorsal approach
utilizing the interval between the abductor pollicis
longus and the extensor pollicis brevis can be used.
APPROACH TO THE
METACARPOPHALANGEAL AND
INTERPHALANGEAL JOINTS AND
PHALANGES
Metacarpophalangeal (MCP) and interphalangeal
(IP) joints are approached commonly in cases of
displaced intra-articular fractures requiring inter-
nal fixation as well as cases requiring arthroplasty 9
due to chronic degenerative changes. Similarly, pha-
langeal fractures that are not amenable to closed
reduction necessitate ORIF. The dorsal approach is
more commonly used. In this approach, the incision
starts about 2 cm proximal to the joint or fracture
and extends about 2 cm distal. The incision may be
straight or curvilinear. Dorsal veins may be encoun-
tered, and care should be taken to preserve them if
possible. Subcutaneous dissection is extended care-
fully to expose the extensor hood overlying the
joint. The extensor hood may then be incised either
through the ulnar sagittal band or may be split lon-
gitudinally on the mid-dorsum. The dorsal capsule
deep to the tendon is incised in the same direction,
and the joint is entered. A similar approach is used
for the IP joints by splitting the extensor tendon
dorsally and entering the joint space.10
Less frequently, the joints may need to be
accessed from the volar side due to non-reducible
dislocation or a volar fracture fragment that may be
too difficult to manipulate dorsally. In these cases,
a zigzag incision is centered volarly over the joint to
avoid placing a straight incision across the MCP or
IP crease. Through the incision, the subcutaneous
tissue is carefully dissected while remaining cog-
nizant of the neurovascular bundle on each side of
the field. Next, the A1 pulley (MCP approach) or A3
(PIP approach) are identified and released. As the
tendon is retracted, the floor of the tendon sheath
in this area is longitudinally incised to give access
to the underlying joint. A similar technique may be
used to divide the A1 pulley in the cases of stenosing
tenosynovitis without the need for bone exposure.
280  Surgical approaches to the hand and wrist
Figure 32.5  Zigzag incision: This approach is
used for volar access to the hand and digits and
is applicable in repair of flexor tendon injury as
well as Dupuytren contracture.
VOLAR OR MID-LATERAL
APPROACH TO THE FINGERS
The volar approach to the fingers is frequently
used in repair of flexor tendons. The incisions are
designed in a zigzag pattern,11 extending obliquely
from one IP crease to the next and p ­ roximally to
the MCP crease (Figure 32.5). If needed, a simi-
lar pattern can be extended into the palm. Deep
to the skin incision, the subcutaneous t­issue
is carefully dissected to expose  the underlying
flexor tendon sheath. The tip of  ­triangular flap
is then carefully mobilized and lifted while pro-
tecting the neurovascular bundle. These flaps
are retracted after a “tacking” suture is placed in
them. The tendon sheath is incised transversely
in the areas of interest to give access to the ten-
don. Care should be taken not to ­ completely
incise crucial pulleys (A2 and A4) that may affect
finger excursion.12
A mid-lateral incision may be used to access finger
fractures or tendon injuries. The incision is placed on
the lateral aspect of the digit above the level of the
neurovascular bundle. The incision is marked with
the finger in full flexion to extend from the dorsal
aspect of the DIP crease to the dorsal aspect of the
Figure 32.6  Mid-lateral incision: Incision is
designed with finger in full flexion. The mid-­
lateral incision is drawn to connect the dorsal-
most points of the interphalangeal joint crease.
PIP crease (Figure 32.6). This line may be extended
proximally and distally as needed.
Frequently, surgical injuries in the hand and
wrist may be accessed through more than one
approach. The approach of choice is often dictated
by surgeon experience and comfort level. It  may
also be influenced by other factors, including the
presence of a traumatic opening in the skin or
pre-existing deformity. Familiarity with various
approaches allows the surgeon to remain flexible
and adaptable to multiple scenarios encountered.
REFERENCES
1. Tay SC, Shin AY. Surgical approaches to the
carpus. Hand Clin. 2006;22():421–434.
2. Cardoso R, Szabo RM. Wrist anatomy and
surgical approaches. Orthop Clin North Am.
2007;38():127–148.
3. Catalano LW, Zlotolow DA, Lafer M,
Weidner Z, Barron OA. Surgical exposures
of the wrist and hand. J Am Acad Orthop
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Suggested reading  281
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SUGGESTED READING
Operative Techniques in Orthopaedic
Surgery: Part 6. Hand, Wrist, and Forearm.
Philadelphia, PA: Lippincott, Williams, and
Wilkins. Vol. 3;2093–3029.
Surgery

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