Essentials of plastic surgery janis free download

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Essentials of

Plastic Surgery A UT Southwestern Medical Center Handbook

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Essentials of

Plastic Surgery A UT Southwestern Medical Center Handbook Second Edition

Edited by

Jeffrey E. Janis, MD, FACS Professor and Executive Vice Chairman, Department of Plastic Surgery, Ohio State University; Chief of Plastic Surgery, University Hospital, Columbus, Ohio With Illustrations by Amanda L. Good, MA and Sarah J. Taylor, MS, BA

Quality Medical Publishing, Inc.

CRC Press

Taylor & Francis Group

2014

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CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20140114 International Standard Book Number-13: 978-1-4822-3844-0 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www. copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-7508400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

To my wife, Emily, our children, Jackson and Brinkley, and to my mother and father­—all of whom have shaped, molded, and influenced my life and career beyond measure— and to all of plastic surgery, to whom this book belongs

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Contributors Samer Abouzeid, MD

Prosper Benhaim, MD

Lee W.T. Alkureishi, MBChB, MRCS Doctor, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Brian P. Bradow, MD Assistant Clinical Professor, Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois

Fellow, Craniofacial and Pediatric Plastic Surgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Associate Professor and Chief of Hand Surgery, Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, Los Angeles, California

Jonathan Bank, MD

John L. Burns, Jr., MD Clinic Instructor, Department of Plastic Surgery, University of Texas Southwestern Medical Center; Dallas Plastic Surgery Institute, Dallas, Texas

Zach J. Barnes, MD Clinical Assistant Professor of Plastic Surgery, Department of Plastic Surgery, Ohio State University, Columbus, Ohio

Daniel R. Butz, MD Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Deniz Basci, MD

Resident, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Daniel O. Beck, MD Aesthetic Fellow, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Amanda Y. Behr, MA, CMI, FAMI Assistant Professor, Department of Medical Illustration, Georgia Regents University, Augusta, Georgia

Carey Faber Campbell, MD

Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

David S. Chang, MD Assistant Clinical Professor, Department of Surgery, University of California, San Francisco, San Francisco, California Tae Chong, MD Assistant Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

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Contributors

James B. Collins, MD Resident, Department of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Michael S. Dolan, MD, FACS Hand Surgeon, Department of Orthopedic Surgery, Jackson-Madison County General Hospital, Jackson, Tennessee

Fadi C. Constantine, MD

Chief Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Private Practice, Department of Plastic Surgery, Paramus, New Jersey

Aesthetic Surgery Fellow, Department of Plastic Surgery, Manhattan Eye, Ear, and Throat Hospital, New York, New York

Kristin K. Constantine, MD

Fellow, Otolaryngology-Head & Neck Surgery, New York Head & Neck Institute, New York, New York

Melissa A. Crosby, MD, FACS Associate Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Marcin Czerwinski, MD, FRCSC, FACS

Assistant Professor of Surgery, Division of Plastic Surgery, Department of Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Phillip B. Dauwe, MD Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Michael E. Decherd, MD, FACS

Clinical Assistant Professor, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas

Chantelle M. DeCroff, MD

Resident, Department of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Christopher A. Derderian, MD

Assistant Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Children’s Medical Center, Dallas, Texas

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Jordan P. Farkas, MD

Douglas S. Fornfeist, MD Assistant Professor, Department of Orthopedic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas Sam Fuller, MD Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois C. Alejandra Garcia de Mitchell, MD Adjunct Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center San Antonio, San Antonio, Texas Patrick B. Garvey, MD, FACS

Associate Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas

Ashkan Ghavami, MD

Assistant Clinical Professor, Department of Plastic Surgery, David Geffen UCLA School of Medicine, Los Angeles, California; Private Practice, Ghavami Plastic Surgery, Beverly Hills, California

Amanda A. Gosman, MD

Associate Clinical Professor, Residency Training Program Director, Division of Plastic and Reconstructive Surgery, University of California, San Diego, San Diego, California

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Contributors Matthew R. Greives, MD

Craniofacial Fellow, Children’s Hospital of Pittsburgh, University of Pittsburgh Department of Plastic Surgery, Pittsburgh, Pennsylvania

Adam H. Hamawy, MD, FACS

Private Practice, The Juventus Clinic, New York, New York

Bridget Harrison, MD Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Bishr Hijazi, MD Private Practice, Nevada Surgical Institute, Las Vegas, Nevada John E. Hoopman, CMLSO

Certified Medical Laser Specialist, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Tarik M. Husain, MD

Attending Orthopaedic/Sports Medicine Surgeon and Hand Surgeon, OrthoNOW, Doral, Florida; Attending Plastic and Hand Surgeon, MOSA Medspa, Miami Beach, Florida

Jeffrey E. Janis, MD, FACS Professor and Executive Vice Chairman, Department of Plastic Surgery, Ohio State University; Chief of Plastic Surgery, University Hospital, Columbus, Ohio Charles F. Kallina IV, MD, MS

Assistant Professor, Department of Surgery; Hand Surgeon, Department of Orthopedic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Phillip D. Khan, MD

Aesthetic Surgery Fellow, The HunstadKortesis Center for Cosmetic Plastic Surgery & Medspa, Charlotte, North Carolina

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Rohit K. Khosla, MD

Assistant Professor, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California

Grant M. Kleiber, MD Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois Reza Kordestani, MD

Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Essie Kueberuwa, MD, BSc (Hons)

Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Huay-Zong Law, MD

Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Danielle M. LeBlanc, MD, FACS Private Practice, Department of Plastic and Reconstructive Surgery, Forth Worth Plastic Surgery Institute, Fort Worth, Texas Michael R. Lee, MD Plastic Surgeon, The Wall Center for Plastic Surgery, Shreveport, Louisiana Jason E. Leedy, MD Private Practice, Mayfield Heights, Ohio Benjamin T. Lemelman, MD

Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Joshua A. Lemmon, MD

Plastic and Hand Surgeon, Regional Plastic Surgery Associates, Richardson, Texas

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Contributors

Raman C. Mahabir, MD, MSc,

FRCSC, FACS Vice Chair, Associate Professor, Chief of Microsurgery, Department of Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Janae L. Maher, MD

Resident, Division of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Menyoli Malafa, MD

Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

David W. Mathes, MD Associate Professor of Surgery, Division of Plastic and Reconstructive Surgery, University of Washington, Seattle, Washington Ricardo A. Meade, MD Plastic Surgeon, Department of Plastic Surgery, University of Texas Southwestern Medical Center; Private Practice, Dallas Plastic Surgery Institute, Dallas, Texas Blake A. Morrison, MD Medical Director, The Advanced Wound Center, Clear Lake Regional Medical Center, Webster, Texas Scott W. Mosser, MD

Private Practice, San Francisco, California

Purushottam A. Nagarkar, MD Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

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Karthik Naidu, DMD, MD Attending Surgeon, Division of Oral and Maxillofacial Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas Kailash Narasimhan, MD

Chief Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Trang Q. Nguyen, MD

Fellow, Plastic and Reconstructive Surgical Service, Memorial Sloan-Kettering Cancer Center, New York, New York

Sacha I. Obaid, MD

Medical Director, North Texas Plastic Surgery, Southlake, Texas

Babatunde Ogunnaike, MD

Vice Chairman and Chief of Anesthesia Services, Parkland Hospital, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas

Eamon B. O’Reilly, MD, LCDR MC US Navy

Staff Surgeon, Department of Plastic Surgery, Naval Medical Center San Diego, San Diego, California

Thornwell Hay Parker III, MD, FACMS

Volunteer Faculty, Department of Plastic Surgery, University of Texas Southwestern Medical Center; Staff, Department of Plastic Surgery, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas

Wendy L. Parker, MD, PhD, FRCSC, FACS Associate Professor, Division of Plastic Surgery, Department of Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

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Contributors Jason K. Potter, MD

Clinical Assistant Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Benson J. Pulikkottil, MD Plastic Surgeon, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

xi

Kendall R. Roehl, MD

Assistant Professor, Division of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Jason Roostaeian, MD

Smita R. Ramanadham, MD

Clinical Instructor, Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California

Rey N. Ramirez, MD

Michel Saint-Cyr, MD, FRCSC Professor of Plastic Surgery, Practice Chair, Department of Plastic Surgery, Mayo Clinic, Rochester, Minnesota

Senior Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Pediatric Hand Surgeon, Shriners Hospital of Erie, Erie, Pennsylvania

Timmothy R. Randell, MD

Douglas M. Sammer, MD Assistant Professor, Program Director, Hand Surgery Fellowship, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Lance A. Read, DDS

Kevin Shultz, MD Plastic Surgeon, Department of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Services Center College of Medicine, Temple, Texas

Orthopedic Surgery Resident, Department of Orthopedic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Assistant Professor of Surgery; Director, Division of Oral and Maxillofacial Surgery, Department of Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

Gangadasu Reddy, MD, MS

Fellow in Hand and Microsurgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Edward M. Reece, MD, MS

Attending Surgeon, St. Joseph’s Medical and Trauma Center, Phoenix, Arizona

José L. Rios, MD Private Practice, Joliet, Illinois Luis M. Rios, Jr., MD

Adjunct Clinical Professor, Department of Surgery, University of Texas Health Science Center−RAHC, San Antonio, Texas

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Christopher M. Shale, MD

Private Practice, Department of Plastic and Reconstructive Surgery, McKay-Dee Dermatology and Plastic Surgery, Ogden, Utah

Deana S. Shenaq, MD Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois Alison M. Shore, MD

Zaccone Family Fellow in Reconstructive Microsurgery, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

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Contributors

Amanda K. Silva, MD

Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois

Holly P. Smith, BFA

Owner and Creative Director, HP Smith Design, Dallas, Texas

Georges N. Tabbal, MD Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Sumeet S. Teotia, MD

Assistant Professor of Plastic Surgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Charter Plastic Surgeon, Alliance of Smiles, San Francisco, California

Chad M. Teven, MD Resident, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois Jacob G. Unger, MD

Chief Resident, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Dinah Wan, MD Medical Doctor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

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Russell A. Ward, MD Assistant Professor, Department of Surgery; Director, Musculoskeletal Oncology, Department of Orthopedic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas Robert A. Weber, MD Professor and Vice Chair of Education, Department of Surgery; Chief, Section of Hand Surgery, Division of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas Adam Bryce Weinfeld, MD Faculty, Department of Pediatric Plastic Surgery, University of Texas Southwestern Medical Center Residency Programs at Seton Healthcare Family; Attending Plastic Surgeon, Institute for Reconstructive Plastic Surgery of Central Texas & Dell Children’s Medical Center of Central Texas, Austin, Texas Dawn D. Wells, PA-C, MPAS

Physician Assistant, Advanced Dermasurgery Associates, Highland Village, Texas

Daniel S. Wu, MD Medical Doctor, Department of Plastic Surgery, Scott and White Healthcare and Texas A&M Health Sciences Center College of Medicine, Temple, Texas

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Foreword

When the first edition of Essentials of Plastic Surgery by Dr. Jeffrey Janis was published in 2007, it immediately achieved spectacular success worldwide, fulfilling its defined role (according to the Oxford English Dictionary) as an “indispensible, absolutely necessary” publication. This compact yet comprehensive paperback handbook quickly became the “go-to” resource for plastic surgery residents and faculty alike. As a testament to its popularity, it could be seen stuffed into lab coat pockets of residents throughout the world, its cover worn with use. Essentials, which is filled with valuable information on topics across the entire spectrum of our broad-based specialty, provides an excellent, portable resource for day-to-day education and the practice of plastic surgery. Its easy-to-use outline format is enhanced by numerous illustrations, tips, tables, algorithms, references, and key points. Now, seven years later, the dynamic nature of plastic surgery has mandated another edition of this beloved manual. This edition is even better than the previous one. The architect of Essentials is Dr. Jeffrey Janis, a young, talented surgeon who I have had the pleasure to know and to help mentor when he was a medical student at Case Western Reserve. Even at that early stage of his training, he expressed a strong interest in plastic surgery. Jeff impressed everyone with his intellect, work ethic, and organizational skills. His early promise has borne fruit during his time at the University of Texas Southwestern Medical Center at Dallas and now in his new position at Ohio Statue University Medical Center. He has become a recognized leader in academic plastic surgery and a respected educator and author. This second edition of Essentials of Plastic Surgery continues its emphasis on core content in plastic surgery, as encapsulated by Dr. Janis and a superb group of contributors. The substantial advances in our specialty have been fully incorporated, with 13 new chapters and dozens of new illustrations. New chapters on topics such as fat grafting, perforator flaps, lymphedema, surgical treatment of migraine headaches, and vascularized composite allografts and transplant immunology attest to the new information and extensive updating that is evident in this edition. While remaining compact, the book has grown to 102 chapters and more than 1000 pages, expanding the book’s coverage while making it both current and timely. Updated content is included in every chapter This comprehensive yet concise edition will ensure that Essentials of Plastic Surgery will retain its role as an indispensible element in the fabric of graduate and continuing medical education in plastic surgery. Edward Luce, MD Professor, Department of Plastic Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee

xiii

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Preface It’s hard to believe that it’s been 10 years since I sat at the kitchen table of one of my best friends, José Rios, in Dallas, Texas, where the idea for Essentials of Plastic Surgery was born. At the time, we wanted to create a “quick and dirty one-stop shopping” utility book for medical students, residents, and fellows to provide high-impact information across the spectrum and variety of plastic surgery to better prepare them for their training programs. Essentials was intentionally designed to be a portable reference book, whether for an emergency department consult, an operating room case, a clinic patient, or for teaching conferences. Neither of us had any idea that the book would turn into an item that is used by so many people in the United States and around the world. A testament to its success has been not only the number of copies sold, but the number of requests for a second edition. In the 6 years that have passed since the first edition was released, there have been many significant changes in the field of plastic surgery, so it was high time to produce an updated book. In this second edition, we have expanded the number of chapters from 88 to 102. This reflects the increasing knowledge and understanding of plastic surgery that has occurred since 2007. New chapters such as Fundamentals of Perforator Flaps, Vascularized Composite Allografts and Transplant Immunology, Negative Pressure Wound Therapy, Surgical Treatment of Migraine Headaches, Face Transplantation, Augmentation-Mastopexy, Nipple-Areolar Reconstruction, Foot Ulcers, Lymphedema, Distal Radius Fractures, Hand Transplantation, Facial Analysis, and Fat Grafting join updated chapters across the entire table of contents. The book retains its familiarity, though, in that it is still divided into seven parts: Fundamentals and Basics; Skin and Soft Tissue; Head and Neck; Breast; Trunk and Lower Extremity; Hand, Wrist, and Upper Extremity; and Aesthetic Surgery. Also retained are the familiar bullet point style, format, and pocket size of the first edition that made it both useful and successful. References have been updated and expanded to guide the reader to classic and definitive articles and chapters. Since this book belongs to all of plastic surgery, authors from around the country were solicited to update, and in many cases completely rewrite, chapters to make the information current, accurate, and contemporary. There have been significant additions of graphics, specifically tables, charts, diagrams, and illustrations, all of which have been created by in-house Quality Medical Publishing illustrators so that the consistency and quality are uniform. This richly augmented graphical content should make the text even more clear to the reader. Ultimately, this book reflects the tremendous effort of a great number of authors and contributors, taking all of the most useful aspects of the first edition and building on that foundation with improvements in content, graphics, and utility. To that end, an electronic format of this book will be released to serve as a useful adjunct to readers as they journey through residency training, fellowship training, or preparation for maintenance of certification.The true test of the book’s utility will lie with you, the reader, as you decide what book to keep in your pocket or on your shelf. My hope is that this one is the book with a cracked and worn spine, creased pages, and absolutely no dust. Jeffrey E. Janis

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Acknowledgments

This book truly is a labor of love that simply could not have come to life without the tremendous time and effort invested in it by so many people. First credit must go to the authors across the country who have taken a significant amount of time to pour through the literature to carefully craft these chapters, and who endured a rigorous editing process where every word and illustration were carefully scrutinized. As they will clearly attest, meticulous attention to detail and emphasis on quality and accuracy demanded much energy and determination. To them, I am sincerely grateful for their time and for the fruits of their efforts. Distinct recognition must also go to Karen Berger, Amy Debrecht, Suzanne Wakefield, Carolyn Reich, Carol Hollett, Makalah Boyer, Hilary Rice, and all of the amazing, hard-working staff at Quality Medical Publishing, who poured their heart and soul into this book and have created a book that could not be done by anyone else. Special gratitude goes to Amanda Good and Sarah Taylor, the illustrators, who deserve an incredible amount of credit for all of the illustrations that make this book pop alive with color, clarity, and flavor. Most of all, with tremendous sincerity, I want to thank my wife, Emily, and our children, Jackson and Brinkley, for their understanding and patience, and above all else, their unconditional love and support. Without them, this book would not be possible, and what is most important, my life would not be complete.

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Contents

Part I 1



Fundamentals

Basics

and

Wound Healing 3 Thornwell Hay Parker III, Bridget Harrison

2 General Management of Complex Wounds

10

Jeffrey E. Janis, Bridget Harrison

3 Sutures and Needles

17

Huay-Zong Law, Scott W. Mosser

4 Basics of Flaps

24

Deniz Basci, Amanda A. Gosman

5 Fundamentals of Perforator Flaps

45

Brian P. Bradow

6 Tissue Expansion

57

Janae L. Maher, Raman C. Mahabir, Joshua A. Lemmon

7 Vascularized Composite Allografts and Transplant 67 Immunology Menyoli Malafa, Tae Chong

8 Basics of Microsurgery

75

David S. Chang, Jeffrey E. Janis, Patrick B. Garvey

9 Biomaterials

87

Dinah Wan, Jason K. Potter

10 Negative Pressure Wound Therapy

107

Janae L. Maher, Raman C. Mahabir

11 Lasers in Plastic Surgery

115

Amanda K. Silva, Chad M. Teven, John E. Hoopman

12 Anesthesia

125

Babatunde Ogunnaike

13 Photography for the Plastic Surgeon

140

Amanda Y. Behr, Holly P. Smith

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xx

Contents

Part II



Skin

and

Soft Tissue

14 Structure and Function of Skin

167

Brian P. Bradow, John L. Burns, Jr.

15 Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma 176 Danielle M. LeBlanc, Smita R. Ramanadham, Dawn D. Wells

16 Burns

195

Reza Kordestani, John L. Burns, Jr.

17 Vascular Anomalies

203

Samer Abouzeid, Christopher A. Derderian, John L. Burns, Jr.

18 Congenital Nevi

211

Dawn D. Wells, John L. Burns, Jr., Kendall R. Roehl

Part III



Head

and

Neck

19 Head and Neck Embryology

217

Huay-Zong Law, Thornwell Hay Parker III

20 Surgical Treatment of Migraine Headaches

223

Jeffrey E. Janis, Adam H. Hamawy

Congenital Conditions 21 Craniosynostosis

234

Carey Faber Campbell, Christopher A. Derderian

22 Craniofacial Clefts

248

Samer Abouzeid, Christopher A. Derderian, Melissa A. Crosby

23 Distraction Osteogenesis

258

Christopher A. Derderian, Samer Abouzeid, Jeffrey E. Janis, Jason E. Leedy

24 Cleft Lip

264

Bridget Harrison

25 Cleft Palate

275

Marcin Czerwinski, Amanda A. Gosman

26 Velopharyngeal Dysfunction

288

Marcin Czerwinski

27 Microtia

295

Danielle M. LeBlanc, Kristin K. Constantine

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Contents

28 Prominent Ear

xxi

304

Jeffrey E. Janis, Adam Bryce Weinfeld

Traumatic Injuries 29 Facial Soft Tissue Trauma

315

James B. Collins, Raman C. Mahabir, Jason K. Potter

30

Facial Skeletal Trauma 323 Jason K. Potter, Adam H. Hamawy

31 Mandibular Fractures

349

Jason K. Potter, Lance A. Read

32 Basic Oral Surgery

358

Jason K. Potter, Karthik Naidu

Acquired Deformities 33 Principles of Head and Neck Cancer: Staging and Management 371 Kristin K. Constantine, Michael E. Decherd, Jeffrey E. Janis

34 Scalp and Calvarial Reconstruction

382

Jason E. Leedy, Smita R. Ramanadham, Jeffrey E. Janis

35 Eyelid Reconstruction

392

Jason K. Potter, Adam H. Hamawy

36 Nasal Reconstruction

403

Fadi C. Constantine, Melissa A. Crosby

37 Cheek Reconstruction

420

Chantelle M. DeCroff, Raman C. Mahabir, David W. Mathes, C. Alejandra Garcia de Mitchell

38 Ear Reconstruction

429

Christopher M. Shale, Amanda A. Gosman, Edward M. Reece

39 Lip Reconstruction

440

James B. Collins, Raman C. Mahabir, Scott W. Mosser

40 Mandibular Reconstruction

454

Patrick B. Garvey, Jason K. Potter

41 Pharyngeal Reconstruction

462

Phillip D. Khan, Raman C. Mahabir

42 Facial Reanimation

478

Daniel S. Wu, Raman C. Mahabir, Jason E. Leedy

43 Face Transplantation

498

Tae Chong

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xxii

Contents

Part IV



Breast

44 Breast Anatomy and Embryology

509

Melissa A. Crosby, Raman C. Mahabir

45 Breast Augmentation

518

Jacob G. Unger, Thornwell Hay Parker III, Michael E. Decherd

46 Mastopexy

538

Joshua A. Lemmon, José L. Rios, Kailash Narasimhan

47 Augmentation-Mastopexy

552

Purushottam A. Nagarkar

48 Breast Reduction

558

Daniel O. Beck, José L. Rios, Jason K. Potter

49 Gynecomastia

573

Daniel O. Beck, José L. Rios

50 Breast Cancer and Reconstruction

580

Raman C. Mahabir, Janae L. Maher, Michel Saint-Cyr, José L. Rios

51 Nipple-Areolar Reconstruction

593

Deniz Basci

Part V



Trunk

and

Lower Extremity

52 Chest Wall Reconstruction

607

Jeffrey E. Janis, Adam H. Hamawy

53 Abdominal Wall Reconstruction

619

Georges N. Tabbal, Jeffrey E. Janis

54 Genitourinary Reconstruction

632

Daniel R. Butz, Sam Fuller, Melissa A. Crosby

55 Pressure Sores

641

Jeffrey E. Janis, Eamon B. O’Reilly

56 Lower Extremity Reconstruction

651

Jeffrey E. Janis, Eamon B. O’Reilly

57 Foot Ulcers

667

Gangadasu Reddy

58 Lymphedema

682

Benson J. Pulikkottil

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Contents

Part VI



Hand, Wrist,

xxiii

Upper Extremity

and

59 Hand Anatomy and Biomechanics

693

Douglas M. Sammer, David S. Chang

60 Basic Hand Examination

708

Jeffrey E. Janis

61 Congenital Hand Anomalies

720

Rey N. Ramirez, Ashkan Ghavami

62 Carpal Bone Fractures

741

Joshua A. Lemmon, Timmothy R. Randell, Prosper Benhaim

63 Carpal Instability and Dislocations

750

Tarik M. Husain, Joshua A. Lemmon

64 Distal Radius Fractures

773

Wendy L. Parker, Georges N. Tabbal, Zach J. Barnes

65 Metacarpal and Phalangeal Fractures

785

Tarik M. Husain, Danielle M. LeBlanc

66 Phalangeal Dislocations

801

Rohit K. Khosla, Douglas S. Fornfeist

67 Fingertip Injuries

810

Joshua A. Lemmon, Tarik M. Husain

68 Nail Bed Injuries

824

Joshua A. Lemmon, Bridget Harrison

69 Flexor Tendon Injuries

834

Joshua A. Lemmon, Prosper Benhaim, Blake A. Morrison

70 Extensor Tendon Injuries

845

Bishr Hijazi, Michael S. Dolan, Blake A. Morrison

71 Tendon Transfers

855

Purushottam A. Nagarkar, Bishr Hijazi, Blake A. Morrison

72 Hand and Finger Amputations

864

David S. Chang, Essie Kueberuwa, Prosper Benhaim

73 Replantation

869

Ashkan Ghavami, Kendall R. Roehl

74 Hand Transplantation

881

Tae Chong

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Contents

75 Thumb Reconstruction

890

Wendy L. Parker, David W. Mathes

76 Soft Tissue Coverage of the Hand and Upper Extremity 901 Sam Fuller, Grant M. Kleiber

77 Compartment Syndrome

912

Alison M. Shore, Benjamin T. Lemelman

78 Upper Extremity Compression Syndromes

922

Prosper Benhaim, Edward M. Reece, Joshua A. Lemmon

79 Brachial Plexus

934

Rey N. Ramirez, Ashkan Ghavami

80 Nerve Injuries

951

Ashkan Ghavami, Prosper Benhaim, Charles F. Kallina IV

81 Hand Infections

964

Tarik M. Husain, Bishr Hijazi, Blake A. Morrison

82 Benign and Malignant Masses of the Hand

981

Russell A. Ward, Melissa A. Crosby

83 Dupuytren’s Disease

995

Douglas M. Sammer

84 Rheumatoid Arthritis

1003

Douglas M. Sammer

85 Osteoarthritis

1017

Wendy L. Parker, Ashkan Ghavami

86 Vascular Disorders of the Hand and Wrist

1026

Kevin Shultz, Robert A. Weber

Part VII



Aesthetic Surgery

87 Facial Analysis

1055

Janae L. Maher, Raman C. Mahabir

88 Nonoperative Facial Rejuvenation

1065

Daniel O. Beck, Sacha I. Obaid, John L. Burns, Jr.

89 Fat Grafting

1099

Phillip B. Dauwe

90 Hair Transplantation

1111

Jeffrey E. Janis, Daniel O. Beck

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Contents

91 Brow Lift

xxv

1122

Jonathan Bank, Jason E. Leedy

92 Blepharoplasty

1132

Kailash Narasimhan, Jason E. Leedy

93 Blepharoptosis

1149

Jason E. Leedy, Jordan P. Farkas

94 Face Lift

1160

Jason Roostaeian, Sumeet S. Teotia, Scott W. Mosser

95 Neck Lift

1189

Ricardo A. Meade, Trang Q. Nguyen, Deana S.Shenaq

96 Rhinoplasty

1203

Michael R. Lee

97 Genioplasty

1230

Lee W.T. Alkureishi, Matthew R. Greives, Ashkan Ghavami

98 Liposuction

1242

Fadi C. Constantine, José L. Rios

99 Brachioplasty

1253

Sacha I. Obaid, Jeffrey E. Janis, Jacob G. Unger, Jason E. Leedy

100 Abdominoplasty

1264

Luis M. Rios, Jr., Sacha I. Obaid, Jason E. Leedy

101 Medial Thigh Lift

1279

Sacha I. Obaid, Jason E. Leedy, Luis M. Rios, Jr.

102 Body Contouring in the Massive-Weight-Loss Patient 1285 Luis M. Rios, Jr., Rohit K. Khosla

Credits

Index

1301 1321

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Essentials of

Plastic Surgery A UT Southwestern Medical Center Handbook

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Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY © 2006 Estate of Pablo Picasso/ARS, New York

Part I Fundamentals and Basics

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Part I opening art: Picasso, Pablo (1881-1973) © Artist Rights Society (ARS), NY. Girl Before a Mirror. 1932. Oil on canvas, 64 0 3 511⁄4 0. Gift of Mrs. Simon Guggenheim. (2.1938). The Museum of Modern Art, New York, NY, USA. Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY. © 2006 Estate of Pablo Picasso/ARS, New York.

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1.

Wound Healing Thornwell Hay Parker III, Bridget Harrison

Three Phases of Wound Healing1-4 1 . Inflammatory phase (days 1 to 6) 2. Fibroproliferative phase (day 4 to week 3) 3. Maturation/remodeling phase (week 3 to 1 year)

Inflammatory Phase (Days 1 to 6)

n  Vasoconstriction: Constriction of injured vessels for 5-10 minutes after injury n  Coagulation: Clot formed by platelets and fibrin, contains growth factors to signal wound repair n  Vasodilation and increased permeability: Mediated by histamine, serotonin (from platelets),

and nitrous oxide (from endothelial cells)

n  Chemotaxis: Signaled by platelet products (from alpha granules), coagulation cascade,

complement activation (C5a), tissue products, and bacterial products

n  Cell migration

• Margination: Increased adhesion to vessel walls • Diapedesis: Movement through vessel wall • Fibrin: Creates initial matrix for cell migration

n  Cellular response

• Neutrophils (24-48 hours): Produce inflammatory products and phagocytosis, not critical to wound healing

• Macrophages (48-96 hours): Become dominant cell population (until fibroblast proliferation), most critical to wound healing; orchestrate growth factors

• Lymphocytes (5-7 days): Role poorly defined, possible regulation of collagenase and extracellular matrix (ECM) remodeling

Fibroproliferative Phase (Day 4 to Week 3) n  Matrix formation

• Fibroblasts: Move into wound days 2-3, dominant cell at 7 days, high rate of collagen synthesis from day 5 to week 3

• Glycosaminoglycan (GAG) production

 Hyaluronic acid first  Then chondroitin-4 sulfate, dermatan sulfate, and heparin sulfate  Followed by collagen production (see later)

• Tensile strength begins to increase at days 4-5

n  Angiogenesis: Increased vascularity from parent vessels; vascular endothelial growth factor

(VEGF)/nitrous oxide

n  Epithelialization (see later)

TIP:  Angiogenesis is the formation of new blood vessels from existing ones. Vasculogenesis is the process of blood vessel formation de novo.

3

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Part I    Fundamentals and Basics

Maturation /Remodeling Phase (Week 3 to 1 Year)

n After 3-5 weeks, equilibrium reached between collagen breakdown and synthesis n Subsequently no net change in quantity n Increased collagen organization and stronger cross-links n Type I collagen replacement of type III collagen, restoring normal 4:1 ratio n Decrease in GAGs, water content, vascularity, and cellular population n  Peak tensile strength at approximately 60 days—80% preinjury strength

Collagen Production n Collagen composed of three polypeptides wound together into a helix n High concentration of hydroxyproline and hydroxylysine amino acids n More than 20 types of collagen based on amino acid sequences n  Type I: Most abundant (90% of body collagen); dominant in skin, tendon, and bone n  Type II: Cornea and hyaline cartilage n  Type III: Vessel and bowel walls, uterus, and skin n  Type IV: Basement membrane only

Growth Factors (Table 1-1) Table 1-1  Growth Factors Growth Factor

Function

FGF VEGF TGF-beta PDGF EGF

Fibroblast and keratinocyte proliferation; Fibroblast chemotaxis Endothelial cell proliferation Fibroblast migration and proliferation Proliferation of fibroblasts, endothelial and smooth muscle cells Keratinocyte and fibroblasts division and migration

Epithelialization n  Mobilization: Loss of contact inhibition—cells at edge of wound or in appendages (in partial

thickness wounds) flatten and break contact (integrins) with neighboring cells.

n  Migration: Cells move across wound until meeting cells from other side, then contact inhibition

is reestablished.

n  Mitosis: As cells at edge are migrating, basal cells further back from the wound edge proliferate

to support cell numbers needed to bridge wound.

n  Differentiation: Reestablishment of epithelial layers are from basal layer to stratum corneum

after migration ceases.

Contraction n  Myofibroblast: Specialized fibroblast with contractile cytoplasmic microfilaments and distinct

cellular adhesion structures (desmosomes and maculae adherens)

n Dispersed throughout granulating wound, act in concert to contract entire wound bed n Appear day 3; maximal at days 10-21; disappear as contraction is complete n  Less contraction when more dermis is present in wound, just as full-thickness skin grafts

have less secondary contraction than split-thickness grafts

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Chapter 1    Wound Healing

5

Types of Wound Healing n  Primary: Closed within hours of creation by reapproximating edges of wound n  Secondary: Wound allowed to heal on its own by contraction and epithelialization n  Delayed primary: Subacute or chronic wound converted to acute wound by sharp debridement,

then closed primarily; healing comparable to primary closure

Factors Affecting Wound Healing Genetic

n Predisposition to hypertrophic or keloid scarring n Hereditary conditions (Table 1-2) n Skin type: Pigmentation (Fitzpatrick type), elasticity, thickness, sebaceous quality, and location

(e.g., shoulder, sternum, earlobe)

n Age: Affects healing rate

Table 1-2  Diseases and Conditions Ehlers-Danlos syndrome

Progeria

Defect

Characteristics

Surgical Intervention

Abnormal collagen structure, production of processing Mutation in LMNA gene

Hyperflexible joints Stretchy, fragile skin Easy bruising Vascular aneurysms Limited growth Full body alopecia Wrinkled skin Atherosclerosis Large head, narrow face, beaked nose Graying of hair Hoarse voice Thickened skin Diabetes mellitus Atherosclerosis Cataracts Cutaneous laxity Yellow skin papules Vision loss Loose, wrinkled skin Hypermobile joints

Not recommended

Werner syndrome

Mutation in WRN gene

Pseudoxanthoma elasticum

Fragmentation and mineralization of elastic fibers Mutation in elastic fibers

Cutis laxa

Not recommended

Not recommended, but reported for temporary improvements

Redundant skin folds can be treated with surgical excision Surgical excision of redundant skin produces temporary benefit but patients do not have wound healing problems

Systemic Health n Comorbidities

• Diabetes • Atherosclerotic disease • Renal failure • Immunodeficiency • Nutritional deficiencies

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Part I    Fundamentals and Basics

Vitamins TIP:  Supplements typically only help when deficiencies exist. n  Vitamin A: Reverses delayed wound healing from steroids; does not affect immunosuppression.

• 25,000 IU by mouth once per day increases tensile strength, or 200,000 IU topical every 8 hours increases epithelialization.

n  Vitamin C: Vital for hydroxylation reactions in collagen synthesis.

• Deficiency leads to scurvy: Immature fibroblasts, deficient collagen synthesis, capillary hemorrhage, decreased tensile strength.

n  Vitamin E: Antioxidant; stabilizes membranes.

• Large doses inhibit healing, but unproven to reduce scarring and may cause dermatitis.

n  Zinc: Cofactor for many enzymes.

• Deficiency causes impaired epithelial and fibroblast proliferation.

Drugs

n  Smoking: Cigarette smoke contains more than 4000 constituents

• Nicotine: Constricts blood vessels, increases platelet adhesiveness • Carbon monoxide: Binds to hemoglobin and reduces oxygen delivery • Hydrogen cyanide: Inhibits oxygen transport

n  Steroids

• Decrease inflammation • Inhibit epithelialization • Decrease collagen production

n  Antineoplastic agents

• Early evidence suggested diminished wound healing, but clinical reports have not substantiated this5

• Few or no adverse effects if administration delayed for 10-14 days after wound closure

n  Anti-inflammatories: May decrease collagen synthesis n  Lathyrogens: Prevent cross-linking of collagen, decreasing tensile strength

• Beta-aminopropionitrile (BAPN): Product of ground peas and d-penicillamine • Possible therapeutic use for decreasing scar tissue

Local Wound Factors n  Oxygen delivery

TIP:  The most common cause of failure to heal and wound infection is poor oxygen delivery associated with various disease states and local conditions (microvascular disease).

• Atherosclerosis, Raynaud’s disease, scleroderma • Adequate cardiac output, distal perfusion, oxygen delivery (hematocrit, oxygen dissociation curve)

• Hyperbaric oxygen: Increases angiogenesis and new fibroblasts

n  Infection

• Clinical infection: Decreases oxygen tension, lowers pH, increases collagenase activity, retards epithelialization and angiogenesis, prolongs inflammation and edema

n  Chronic wound

• Metalloproteases abundant, promote extracellular matrix turnover, slow wound healing • Debridement of chronic wound: Removes excess granulation tissue and metalloproteases, transforms it to an acute wound state, and expedites healing

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Chapter 1    Wound Healing

7

n  Radiation therapy

• Causes stasis/occlusion of small vessels, damages fibroblasts, chronic damage to nuclei

n  Moisture

• Speeds epithelialization

n  Warmth

• Increased tensile strength (better perfusion)

n  Free radicals

• Reactive oxygen species increased by ischemia, reperfusion, inflammation, radiation, vitamin deficiencies, and chemical agents

Scarring n  Hypertrophic scars (HTS) (Fig.1-1)

• Primarily type III collagen oriented

parallel to epidermal surface with abundant myofibroblasts and extracellular collagen • Scar elevated but within borders of original scar; more common than keloids (5%-15% of wounds) Fig. 1-1  Hypertrophic scar.  Predisposition to areas of tension, flexor surfaces  Less recurrence following excision and adjuvant therapy n  Keloid scars (Fig. 1-2) • Derived from Greek chele, or crab’s claw Grow outside original wound borders •  • Disorganized type I and III collagen, hypocellular collagen bundles • Only seen in humans; rare in newborns or elderly • May occur with deep injuries (less common than HTS)  Genetic and endocrine influences (increased growth in puberty and pregnancy)  Rarely regress and more resistant to excision and therapy • Because of high recurrence rates, multimodality therapy recommended6,7 (Table 1-3) Fig. 1-2  Keloid scar. Table 1-3  Keloid Treatments Treatment

Mechanism

Recurrence Rates

Silicone sheeting

Hydration, increased temperature

Corticosteroids

Reduce collagen synthesis and inflammatory mediators Reduce fibroblast production of glycosaminoglycans, increase collagenase Inhibits fibroblast proliferation Modifies collagen synthesis and fibroblast differentiation Removal of abnormal tissue Inhibition of angiogenesis and fibroblasts

Most effective as preventive method 9%-50%

Interferon 5-Fluorouracil Cryotherapy Excision Radiation

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54% 19% 50%-80% obtain volume reduction 50%-100% 2%-33%

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8

Part I    Fundamentals and Basics

n  Widened scars (Fig. 1-3)

• Wide and depressed from wound tension

perpendicular to wound and mobility during maturation phase n  Fetal healing • Potentially scarless healing in first two trimesters • Higher concentrations of type III collagen and hyaluronic acid, no inflammation, no Fig. 1-3  Widened scar. angiogenesis, relative hypoxia n  Scar management8 • Silicone sheeting recommended as soon as epithelialization is complete and should be continued for at least one month   Mechanism of action not known, but suggested mechanisms include increases in temperature and collagenase activity, increased hydration, and polarization of the scar tissue • If silicone sheeting unsuccessful, corticosteroid injections may be used  Potential risks include subcutaneous atrophy, telangiectasia, and pigment changes • Pressure therapy and massage have been recommended and may reduce scar thickness, but support is weak9 • Improvement with topical vitamin E not supported—may cause contact dermatitis10 • Topical onion extract (Mederma, Merz Pharmaceuticals, Greensboro, NC) has not shown improvement in scar erythema, hypertrophy, or overall cosmetic appearance.11

Key Points  The three stages of wound healing are inflammatory phase (macrophage most important), fibroproliferative phase, and maturation phase.

 Peak tensile strength occurs at 42-60 days (80% of original strength).  Epithelialization is initiated by loss of contact inhibition.  The amount of dermis present is inversely proportional to the amount of secondary

contraction (i.e., more dermis equates to less secondary contraction).  Vitamin A is used to reverse detrimental effects of steroids on wound healing.  Hypertrophic scars and keloids are distinguished clinically; both have high recurrence rates unless combined modalities are used.

References 1. Broughton G, Rohrich RJ. Wounds and scars. Sel Read Plast Surg 10:5-7, 2005. 2. Glat P, Longaker M. Wound healing. In Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith’s Plastic Surgery, 5th ed. Philadelphia: Lippincott-Raven, 1997. 3. Janis JE, Kwon RK, Lalonde DH. A practical guide to wound healing. Plast Reconstr Surg 125:230e244e, 2010. 4. Janis JE, Morrison B. Wound healing. Part I: Basic science (accepted by Plast Reconstr Surg 2013). 5. Falcone RE, Nappi JF. Chemotherapy and wound healing. Surg Clin North Am 64:779-794, 1984. 6. Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am 19:505-515, 2011. 7. Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg 23:178-184, 2009.

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Chapter 1    Wound Healing

9

8. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg 110: 560-571, 2002. 9. Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Dermatol Surg 38:414-423, 2012. 10. Khoo TL, Halim AS, Zakaria Z, et al. A prospective, randomized, double-blinded trial to study the efficacy of topical tocotrienol in the prevention of hypertrophic scars. J Plast Reconstr Aesthet Surg 64:e137e145, 2011. 11. Chung VQ, Kelley L, Marra D, et al. Onion extract gel versus petrolatum emollient on new surgical scars: prospective double-blinded study. Dermatol Surg 32:193-219, 2006.

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2. General Management of Complex Wounds Jeffrey E. Janis, Bridget Harrison

General Points1 Algorithmic Approach

n Thorough and comprehensive patient evaluation n Examination and evaluation of the wound n Lab tests and imaging n Assessment, plan, and execution

History

n Age n General health n Presence of comorbidities n Prewound functional and ambulatory capacity n Associated factors that influence wound healing

• Diabetes mellitus • End-stage renal disease • Cardiac disease • Peripheral vascular disease • Tobacco use • Vasculitis • Malnutrition • Steroid therapy • Radiation • Hemophilia

  80% of normal factor VIII levels are recommended in perioperative period

Physical Examination n Assessment of vascular system

• Palpable pulses • Temperature • Hair growth • Skin changes

n Assessment of neurosensory system

• Reflexes • Two-point discrimination/vibratory testing (128 Hz)

10

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Chapter 2    General Management of Complex Wounds

11

Wound Evaluation n  Wound history

n

• Circumstances surrounding injury • History of wound healing problems • Chronicity • Previous diagnostics • Previous treatments Components of wound evaluation

• Location (helps determine underlying causes) • Size  Length, width, depth  Area

• Extent of defect

 Skin; subcutaneous tissue; muscle, tendon, nerve; bone n  Condition of surrounding tissue and wound margins

• Color • Pigmentation • Inflammation/induration • Satellite lesions • Edema

n  Condition of wound bed

• Odor • Necrosis • Granulation tissue • Exposed structures • Fibrin, exudate, eschar • Foreign bodies • Inflammation/infection • Tunneling/sinuses

Laboratory Studies n Complete blood count (CBC)

• Elevated white-cell count? Left shift?

n Blood urine nitrogen (BUN)/creatinine

• Assessment of renal function and hydration status

n Glucose/hemoglobin A1C

• Assessment of hyperglycemia and its trend

 Questions remain regarding appropriate insulin therapy and glucose levels in surgical

patients.2  Tight blood glucose control with intensive insulin therapy and normoglycemia (,110 mg/dl) has shown absolute reduction in risk of hospital death by 3%-4% in some trials.3  When intensive glucose control leads to hypoglycemia (,70 mg/dl), there is an increased risk of death in critically ill patients.4  In patients with or without diabetes, perioperative hyperglycemia (.180 mg/dl) carries a significantly increased risk of infection.5 Normal A1C: 6.0 •   Represents average glucose over previous 120 days.  Although postoperative hyperglycemia and undiagnosed diabetes increase the risk of surgical site infections, elevated hemoglobin A1C values do not correlate.6,7

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Part I    Fundamentals and Basics

n Albumin and prealbumin

Albumin (t1⁄2 , 20 days) • 

 Mild malnutrition: 2.8-3.5 g/dl  Moderate malnutrition: 2.1-2.7 g/dl  Severe malnutrition: Less than 2.1 g/dl  Of 34 preoperative risk factors evaluated in a national VA surgical risk study, preopera-

tive serum albumin level was the most important predictor of 30-day mortality.8 Prealbumin (t1⁄2 , 3 days) •   Rule of fives  Normal: Greater than 15 mg/dl  Mild deficiency: Less than 15 mg/dl  Moderate deficiency: Less than 10 mg/dl  Severe deficiency: Less than 5 mg/dl n Unreliable in infections, inflammation, or recent trauma n Erythrocyte sedimentation rate/C-reactive protein (ESR/CRP) • Nonspecific inflammatory markers • Obtain baseline • Subsequent measurements to help follow potential recurrence of osteomyelitis

Imaging

n  Plain films

• Fractures • Foreign bodies • Osteomyelitis (14%-54% sensitivity; 70% specificity)

n  CT scan

• Abscess • Extent of wound • Tracking/tunneling

n  MRI/MRA

• Osteomyelitis (80%-90% sensitivity; 60%-90% specificity) • Assessment of vascular status

n  Angiography

• Assessment of vascular status

 Contrast-enhanced MRA has overall better diagnostic accuracy for peripheral arterial

disease than CTA or ultrasound and is preferred by patients over contrast angiography.9

 Recommendations for preoperative imaging of lower extremities before free flap

reconstruction vary. Some authors advocate angiography,10 and others recommend preoperative and intraoperative clinical assessment.11,12  Normal imaging does not guarantee finding vessels suitable for anastomosis.

Diagnostic Tests n  Handheld Doppler n  Ankle-brachial index

• Greater than 1.2: Noncompressible (calcified) • 0.9-1.2: Normal • 0.5-0.9: Mixed arterial/venous disease • Less than 0.5: Critical stenosis • Less than 0.2: Ischemic gangrene likely

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Chapter 2    General Management of Complex Wounds

13

n  Transcutaneous oxygen tension (TcPO2)

• Evaluation of response to oxygen administration as a surrogate marker for reversible hypoxia • Greater than 40 mm Hg: Normal • Less than 30 mm Hg: Abnormal

n  Cultures

• Identification of specific microorganisms and sensitivities

n  Biopsy

• Vasculitis • Marjolin’s ulcer/malignancy

 Time to malignant transformation averages 30-year latency period

• Pyogenic granuloma

Assessment

n Working diagnosis n Set treatment goals n Define monitoring parameters

Plan (Reconstructive Ladder)

n Mathes and Nahai13 suggested the reconstructive triangle, including tissue expansion, local

flaps and microsurgery.

n Gottlieb and Krieger14 introduced the reconstructive elevator to emphasize the freedom to rise

directly to a more complex level when appropriate. n Janis et al15 modified the traditional reconstructive ladder to include •  Free tissue transfer dermal matrices and negative •  Tissue expansion pressure wound therapy (Fig. 2-1). • Dermal matrices generally •  Distant flaps consist of collagen and are •  Dermal matrices vascularized from the native wound bed. •  Local flaps  Bilaminate neodermis •  Skin grafts contains outer layer of silicone and inner • Negative pressure wound therapy matrix of collagen and • Primary closure glycosaminoglycans. • Healing by secondary intention • Can be used to cover exposed critical structures, improve cosmesis from skin grafting, and Fig. 2-1  Reconstructive ladder. simplify scalp reconstruction.16 • May prevent need for free flap reconstruction, but require attention to potential complications such as seromas, hematomas, and infection.

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Part I    Fundamentals and Basics

n Erba et al17 proposed a reconstructive matrix with three axes representing technologic

sophistication, surgical complexity, and patient-surgical risk. • Within the infinite number of possibilities in this 3D grid exists a reconstructive matrix of the optimal solutions for a given patient and surgeon (Fig. 2-2).

Surgical complexity (z)

Patient’s surgical risk (y)

Technological sophistication (x)

Fig. 2-2  Hyperbolic representation of the optimal solutions for a given patient and surgeon.

Optimal outcome

n Modified reconstructive ladder

• Useful: Organizes reconstructive solutions in order of complexity • Systematic consideration of the most simple to the most complex solution • Primary closure • Healing by secondary intention • Negative pressure wound therapy • Skin graft • Dermal matrices • Local flap • Regional flap • Distant flap • Tissue expansion • Free tissue transfer

n In the current era of microvascular proficiency, free tissue transfer is no longer a last resort,

and complex solutions often yield superior results to simpler options.

n The use of tissue expansion, prefabrication, and composite flaps enables surgeons to optimize

the balance between donor site preservation and restoration of defect form and function.

Wound Healing Adjuncts n  Hyberbaric oxygen

• May be helpful for foot wounds in patients with diabetes and for osteoradionecrosis

n  Platelet-rich plasma

• Contains high concentration of growth factors in small amount of plasma • Lacks high-level evidence for its use; production methods vary

n  Stem cells

• Potential for regeneration of skin, bone, and cartilage • Adult stem cells may be derived from bone marrow, blood, or adipose tissue • Lack high-level evidence

n  Honey

• Used by ancient Greeks and Egyptians • Antibacterial action against Staphylococcus aureus, Escherichia coli, Haemophilus influenzae, and Pseudomonas spp.18

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Chapter 2    General Management of Complex Wounds

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n  Biologic dressings (Table 2-1) n  Vacuum-assisted closure (VAC)

• First reported by Argenta and Morykwas in 199719 • Increases local blood flow and granulation tissue • Functions by inducing cellular deformation that increases mitotic activity, removing fluid exudate, and potentially damaging cytokines.

• Not recommended if there are exposed blood vessels, malignancy, untreated osteomyelitis, unexplored fistulas, or grossly infected tissues.

Table 2-1  Biologic Dressings Product

Composition

AlloDerm (LifeCell, Branchburg, NJ) SurgiMend (TEI Biosciences, Boston, MA) Integra Meshed Bilayer Wound Matrix (Integra LifeSciences, Plainsboro, NJ) Transcyte (Smith & Nephew, London)

Cadaveric human acellular dermis Bovine-derived acellular dermal matrix Bilayer of outer silicone and inner bovine collagen and glycosaminoglycan matrix Cultured neonatal dermal fibroblasts on silicone/ collagen matrix Human fibroblast–derived dermal substitute Bilayer of bovine collagen and human fibroblast matrix under human keratinocytes Nylon fibers embedded in silicone with chemically bound collagen

Dermagraft (Advanced Tissue Sciences, La Jolla, CA) Apligraf (Organogenesis, Canton, MA) Biobrane (Smith & Nephew, London)

Considerations

n Functional impact n Durability n Individualize treatment to the patient (socioeconomic impact)

• Does the patient need to minimize hospital stay, decrease the need for staged procedures, or get back to work quickly?

n Appearance n Make sure solution not more complicated than problem

Key Points  Successful treatment of any wound first requires comprehensive clinical evaluation of the wound and patient comorbidities.  Blood glucose and nutritional parameters must be optimized preoperatively and postoperatively to prevent surgical site complications.  Preoperative serum albumin is a predictor of postoperative mortality.  New algorithms for reconstruction expand on the reconstructive ladder to allow plans tailored to the defect, donor site morbidity, patient, and surgeon preference.

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Part I    Fundamentals and Basics

References 1. Janis JE, Morrison B. Wound healing. Part II: Clinical applications (accepted by Plast Reconstr Surg 2013). 2. Devos P, Preiser JC. Current controversies around tight glucose control in critically ill patients. Curr Opi Clin Nutr Metab Care 10:206-209, 2007. 3. Vanhorebeek I, Langouche L, Van den Berghe G. Tight blood glucose control: what is the evidence? Crit Care Med 35(9 Suppl):S496-S502, 2007. 4. Finfer S, Liu B, Chittock DR, et al. Hypoglycemia and risk of death in critically ill patients. New Engl J Med 367:1108-1118, 2012. 5. Kwon S, Thompson R, Dellinger P, et al. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg 257:8-14, 2013. 6. King JT Jr, Goulet JL, Perkal MF, et al. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann Surg 253:158-165, 2011. 7. Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 22:607612, 2001. 8. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg 134:36-42, 1999. 9. Collins R, Cranny G, Burch J, et al. A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease. Health Technol Assess 11:iii-iv, xi-xiii, 1-184, 2007. 10. Haddock NT, Weichman KE, Reformat DD, et al. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg 210:66-72, 2010. 11. Isenberg JS, Sherman R. The limited value of preoperative angiography in microsurgical reconstruction of the lower limb. J Reconstr Microsurg 12:303-305, 1996. 12. Lutz BS, Ng SH, Cabailo R, et al. Value of routine angiography before traumatic lower-limb reconstruction with microvascular free tissue transplantation. J Trauma 44:682-686, 1998. 13. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, & Technique. St Louis: Quality Medical Publishing, 1997. 14. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 93:1503-1504, 1994. 15. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg 127(Suppl 1):S205-S212, 2011. 16. Komorowska-Timek E, Gabriel A, Bennett DC, et al. Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors. Plast Reconstr Surg 115:1010-1017, 2005. 17. Erba P, Ogawa R, Vyas R, et al. The reconstructive matrix: a new paradigm in reconstructive plastic surgery. Plast Reconstr Surg 126:492-498, 2010. 18. Song JJ, Salcido R. Use of honey in wound care: an update. Adv Skin Wound Care 24:40-44, 2011. 19. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 38:563-576, 1997.

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3. Sutures and Needles Huay-Zong Law, Scott W. Mosser

Qualities of Suture Materials: Essential Vocabulary1 Permanence: Absorbable Versus Nonabsorbable n  Absorbable

• Lose at least 50% of their strength in 4 weeks • Eventually completely absorbed • Degradation process   Hydrolytic

Process for synthetic sutures Minimal inflammation   Proteolytic  Enzyme-mediated  Process for natural sutures (e.g., gut, from beef or sheep intestine)  More inflammation leads to more scarring around the suture site. n  Nonabsorbable • Induce a cell-mediated reaction until the suture becomes encapsulated  

Configuration

n  Monofilament versus multifilament (twisted or braided)

• Monofilament sutures slide through tissue with less friction and are less likely to harbor infective organisms.

• Multifilament sutures are stronger, more pliable, and less sensitive to crimping and crushing, which may create a weak spot.

TIP:  Gut sutures do not fit into either category but behave more like monofilament sutures. n  Barbed versus nonbarbed (twisted or braided)2-5

• Addition of one-way barbs to maintain tension in knotless closure • Similar strength and postoperative complication profile to nonbarbed suture • Faster deployment than nonbarbed suture, but unable to backtrack and may trap fibers from laparotomy sponges and surgical drapes

• Range of absorbable and nonabsorbable barbed sutures available from multiple vendors

Knot Security

The force necessary to cause a knot to slip n Knot security is proportional to the coefficient of friction and the ability of the suture to stretch. n More knot security means fewer throws are necessary to tie a reliable knot. n Braided sutures (e.g., silk, Vicryl) generally have better knot security than monofilament sutures (e.g., Prolene, nylon).

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Elasticity

The tendency of a suture to return to its original length after stretching n Elastic sutures stretch in edematous wounds, then return to their original size while maintaining tension. n Inelastic sutures (e.g., steel) cut through edematous tissues instead of forgiving the added tension.

Memory

The tendency of a suture material to return to its original shape (similar to stiffness) n Sutures with more memory are less pliable and more difficult to handle. n More memory leads to less knot security.

Fluid Absorption and Capillarity

Fluid absorption is the amount of fluid retained by a suture. Capillarity is the tendency of fluid to travel along the suture. n Capillarity correlates with increased adhesion of bacteria and infection.6,7

Cost

n Cost includes both the suture material and the needle. n Sutures attached to precision needles (which are sharper and made of high-grade alloys) are

more expensive than sutures with standard needles.

Visibility

n Dyeing aids in visibility during placement and removal, but buried sutures may be undesirably

visible.

n Braided sutures are usually visible even if undyed, because they become saturated with blood

intraoperatively.

TIP:  The United States Pharmacopoeia (USP) rating system is often used.8 Diameters are given in #-0 values based on USP breaking strength rating, not the width of the suture. Two different sutures with the same number can have different diameters (e.g., a 3-0 stainless steel suture is thinner than a 3-0 silk suture but has the same breaking strength).

Needle Configurations9 Point Configuration (Fig. 3-1) n  Cutting needles

• Have sharp edges along the length of the needle tip; better at penetrating tough tissues • Skin and dermis are sutured with cutting needles. Conventional cutting versus reverse cutting needles • 

  Conventional cutting needles: Sharp edge on the interior of the curve that creates a weak

point on the tract where suture can cut through skin

  Reverse cutting needles: Sharp edge on the exterior of the curve; preferable for skin closure

n  Taper needles

• Taper needles have a sharp tip but no sharp edge. • Tissue spreads around the needle instead of being cut by it. • Suture material is less likely to cut through tissue if the tract is made with a taper needle. • Taper needles are typically used for tendon and deep tissue closure (fascia).

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Chapter 3    Sutures and Needles Type of Needle

Shape of Needle

Conventional cutting needle

point

19

Indication for Use

Skin

body

point

Reverse cutting needle

body

point

Side-cutting (spatula) needle

body

point

Taper-point needle

body

point

Blunt-tip needle

body

Skin Oral/nasal mucosa Ophthalmic surgery Fascia Tendon/ligament repair Pharynx Cartilage Skin Cornea Microsurgery Abdominal organs Myocardium Peritoneum Dura Fascia, hernia repair Subcutaneous tissues Microsurgery Gynecologic surgery Liver Kidney Gynecologic surgery Obstetric surgery High-risk patients

Fig. 3-1  Types of commonly used needles.

Size (Figs. 3-2 and 3-3)

CHORD LENGTH Swage

n  Curvature

Point

• Most needles used in plastic surgery have a three-

Needle Diameter

radius eighths circle curvature. • A one-fourth curve may be better for microsurgical Body applications. • Some wound geometries require a one-half or Needle five-eighths curve to facilitate tissue handling. Length n  Length Fig. 3-2  Anatomy of a needle. Needle length: Circumferential distance along the •  curve Chord length: Straight-line distance between the point and the eye (nearly always swaged) • 

1/4 circle

3/8 circle

1/2 circle

5/8 circle

Fig. 3-3  Curvature of a needle.

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Part I    Fundamentals and Basics

n  Diameter

• Determined by the balance between providing sufficient material strength and the smallest diameter possible for the required suture size

Tab

C

TIP:  Vendors use needle codes for specific needle configurations. Common plastic surgery codes include BV (blood vessel), CT (circle taper), P/PS (plastic surgery), RB (renal bypass), SH (small half [circle]).

Factors That Guide Suture Choice (Tables 3-1 and 3-2)9-12

S N

P P

Absorbable Versus Nonabsorable

n Rapidly absorbing suture can be used for layers closed under minimal tension (e.g., gut suture

to close mucosa or skin after deep sutures are placed). n Absorbable sutures that maintain strength for 4-6 weeks are used for closures under short-term tension (e.g., Vicryl or PDS to close fascia and subcutaneous tissue). n Considerable long-term tension requires permanent sutures (e.g., nylon, polypropylene, or polyester for bone anchoring, ligament, and tendon repair). n Choose an absorbable suture that loses strength comparable to the timing of wound strength recovery12 (Fig. 3-4).

P

S

*Et †U.

n Caliber is largely dictated by the strength of suture needed. n Choose the smallest-caliber suture that provides sufficient strength.

T ype of Tissue and Needle Choice

n Generally, use permanent sutures on taper needles for fascia, tendon, or cartilage under

tension.

% Strength retained

Caliber

n Use absorbable sutures on cutting needles for subcutaneous, dermis, and skin closures.

Table 3-1  Qualities of Absorbable Sutures

Fig be 80 1y

Time to 50% Strength

Configuration

Reactivity

Memory

Gut Fast Plain Chromic Polyglytone 6211 (Caprosyn*) Poliglecaprone 25 (Monocryl†) Glycomer 631 (Biosyn†) Glycolide/lactide copolymer Low molecular weight (Vicryl Rapide*) Regular (Polysorb†, Vicryl*) Polyglycolic acid (Dexon S†)

Unpredictable 5-7 days 7-10 days 10-14 days 5-7 days 7-10 days 2-3 weeks 5 days

Monofilament Monofilament Monofilament Monofilament Monofilament Monofilament Braided

High High High Low Low Low Low

Low Low Low Medium Medium Medium Low

W

Low Low

Low Low

Pa

Polyglyconate (Maxon†) Polydioxanone (PDS II*)

4 weeks 4 weeks

Braided Monofilament or braided Monofilament Monofilament

Low Low

High High

Composition (proprietary name)

2-3 weeks 2-3 weeks

*Ethicon. †U.S. Surgical Corporation.

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Chapter 3    Sutures and Needles

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Table 3-2  Qualities of Nonabsorbable Sutures Composition (proprietary name)

Tensile Strength

Configuration

Reactivity

Memory/ Handling

Silk Nylon Monofilament (Ethilon*, Monosof-Dermalon†) Braided (Nurolon*, Surgilon†) Polypropylene (Prolene*, Surgipro†) Polybutester Uncoated (Novafil†) Coated (Vascufil†) Polyester Uncoated (Mersilene*) Coated (Ethibond*, Surgidac†, Ticron†) Surgical steel

Lost in 1 year 81% at 1 year, 72% at 2 years,

Braided

High

22/Good

Monofilament

Low

1/Fair

66% at 11 years Indefinite

Braided Monofilament

Low Low

22/Good 11/Poor

Indefinite Indefinite

Monofilament Monofilament

Low Low

1/Fair 2/Good

Indefinite Indefinite

Braided Braided

Moderate Moderate

22/Good 22/Good

Indefinite

Monofilament or braided

Low

11/Poor

% Strength retained

*Ethicon. †U.S. Surgical Corporation. 100 90 80 70 60 50 40 30 20 10 0

Plain gut Maxon, PDS Vicryl, Polysorb, Dexon II Monocryl Chromic gut Strength recovery of healing skin

0

5

10

15

20

25

30

35

40

Days

Fig. 3-4  Suture absorption and wound strength recovery. After a procedure, skin strength can be expected to regain 5% of its original strength within a week, nearly 50% within 4 weeks, and 80% within 6 weeks of skin closure. Even after collagen maturation is complete (6 months to 1 year postoperatively), a wound will only regain 80% of its original strength.

Wound Contamination and Inflammation TIP:  Monofilament sutures should be used for contaminated and infected wounds to prevent harboring bacteria in the suture material. n Wound infection accelerates the process of suture absorption.

Patient Factors

n Patient reliability, age, and overall wound-healing capability affect how long the sutures must

maintain closure tension.

TIP:  In thin patients, buried knot configurations with braided, absorbable suture will prevent palpability of sutures after surgery.

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Part I    Fundamentals and Basics

Microsutures and Needles (see Chapter 8) n Suture choice depends on vessel or structure size.

• 8-0 is used for large (4 mm) vessels (e.g., radial and ulnar arteries). • 9-0 is used for 3-4 mm vessels (e.g., internal mammary, dorsalis pedis, and posterior tibial arteries).

• 10-0 is used for 1-2 mm structures (e.g., digital arteries and nerves). • 11-0 is used for very small (,1 mm) vessels, such as those in children and infants.

n Microsutures behave similarly in tying and memory characteristics at these diameters. n Sutures are nearly always monofilament synthetic (e.g., nylon or polypropylene).

Suture Removal Potential Complication: Railroad Track Scar (Fig. 3-5)

A “railroad track” scar is the formation of punctate scars and parallel rows of scar beneath them. n The punctate component of the scars results from delayed suture removal. • Epithelial cells that abut a skin suture form a cylindrical cuff and grow downward along the suture. • The cells continue to develop after suture removal and keratinize the length of the suture tract, resulting in inflammation and punctate scar formation. n  Parallel rows result from pressure necrosis of the skin and subcutaneous tissue beneath the external suture. This can be prevented by tying sutures loosely enough to allow postoperative edema.

Fig. 3-5  Railroad track scar deformity.

Other Closure Materials Stainless Steel Staples13

n Nonreactive, but inelastic and offer imprecise epidermal approximation n Least ischemic method of closure n Faster than sutures without clinically significant difference in cosmetic result, infection, or ease

of removal

Cyanoacrylate

n Rapid and effective for well-aligned wounds under no tension, but imprecise edge

approximation

n Does not support significant skin edge tension during healing n Decreased rates of postoperative surgical site infections in some studies14,15 n Use in combination with polyester mesh (e.g., Prineo) compared with intradermal sutures

resulted in faster closure (1.5 versus 6.7 minutes for 22 cm incision on average) with no statistical difference in cosmetic outcome16 • No difference in infection rate was seen. • Blistering occurred in 2.4% (2 of 83 patients) of polyester/cyanoacrylate closure sites compared with 0% of the intradermal suture sites.

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Key Points  In a contaminated wound, monofilament suture should be used.  Tissue under significant long-term tension should be closed with permanent suture only.

suture that loses strength comparable to the timing of wound  Choose an absorbable 12

strength recovery.  Of the absorbable sutures available for skin closure, only fast-absorbing plain gut and Vicryl Rapide are absorbed in time to prevent punctate scar formation.  To avoid railroad track scars, sutures in the skin layer should be removed promptly. Therefore the final skin layer should not be closed under tension, and a gaping skin wound should be approximated first with deep sutures.