HYPERTROPHIC SCARS & KELOIDS
In response to any injury severe enough to break the continuity of the skin or produce necrosis, the skin heals with scar formation. Under ideal circumstances, a fine, flat hairline scar will result. The details of wound healing are presented in Chapter 6.
However, hypertrophy may occur, causing the scar to become raised and thickened, or a keloid may form. A keloid is a true tumor arising from the connective tissue elements of the dermis. By definition, keloids grow beyond the margins of the original injury or scar; in some instances, they may grow to enormous size. (Figure 41–9)
A keloid scar—the excess growth of scar tissue at the site of a healed skin injury.
Hypertrophic scars and keloids are distinct entities, and the clinical course and prognosis are quite different in each case. The overreactive process that results in thickening of the hypertrophic scar ceases within a few weeks—before it extends beyond the limits of the original scar—and in most cases, some degree of maturation occurs and gradual improvement takes place. In the case of keloids, the overreactive proliferation of fibroblasts continues for weeks or months. By the time it ceases, an actual tumor is present that typically extends well beyond the limits of the original scar, involves the surrounding skin, and may become quite large. Maturation with spontaneous improvement does not usually occur.
More recent research has shown differences on a biochemical level that can be quite complex. In essence though, it is understood that fibroblasts in both disorders display an increase in procollagen. This is compensated for in hypertrophic scars but not in keloids. This results in an increased ratio of type 1 to type 3 collagen in keloids.
The most frustrating aspect of hypertrophic and keloid treatment for both patient and care provider alike is the high incidence of recurrence. Much work has gone into developing techniques to avoid and treat these scar problems, with mixed results. As this has become more evident, providers have become more specialized and aggressive with treatment options. More recent studies looking at treatments such as interferon, 5-flurouracil injections and bleomycin injections have shown some promise. But no therapy has shown to conclusively treat these problems.
Since nearly all hypertrophic scars undergo some degree of spontaneous improvement, they do not require treatment in the early phases. If the scar is still hypertrophic after 6 months, surgical excision and primary closure of the wound may be indicated, but recurrence is between 45% and 100% if no other treatments are provided. Improvement may be expected when the hypertrophic scar was originally produced by excessive endothelial and fibroblastic cell proliferation, as is present in open wounds, burns, and infected wounds. However, little or no improvement can be anticipated if the hypertrophic scar followed uncomplicated healing of a simple surgical incision. Improvement of hypertrophic scars across flexion surfaces such as the antecubital fossa or the fingers requires a procedure such as a Z-plasty to change the direction of the scar.
Pressure may help flatten a potentially hypertrophic scar. It is particularly useful for burn scars. A measured elastic garment or face mask (Jobst) is applied to the scarred area and provides continued pressure that causes realignment and remodeling of the collagen bundles. Pressure should be applied early, continuously, and for 6-12 months. Use of intermittent pressure (eg, only at night) or pressure applied after the hypertrophic scar is established (6-12 months) is of little value.
Additional methods of decreasing the thickness of hypertrophied scars include silicone sheeting applied early and continuously for weeks or months. Laser therapy, such as CO2, pulse dye, and flash lamps, have been examined with no definitive long-term success noted when used alone. Radiotherapy has a place in scar management although it is somewhat controversial due to potential carcinogenesis following procedure and the lack of long-term follow up studies. Cryotherapy has shown some success with small scars only. Interestingly enough, the simple use of paper tape over fresh surgical incisions for several weeks has shown to be a potential preventive treatment.
The first-line treatment for keloids and second-line therapy for intractable hypertrophic scars is still injection of triamcinolone acetonide, 10 mg/mL (Kenalog-10 Injection), directly into the lesion. Corticosteroid injection decreases fibroblast proliferation and collagen synthesis as well as suppressing pro-inflammatory markers. There is some evidence that keloids may respond better to early treatment rather than to late treatment.
Lesions are injected every 3-4 weeks, and treatment should not be carried out longer than 6 months. A general rule of thumb is to inject 10 mg of triamcinolone for each centimeter in length of the scar. The following dosage schedule is used:
For larger lesions, the maximum dose should be 120 mg. The maximum doses for each treatment for children are as follows:
There is a tendency to inject the drug into the scar too often or in too high a dosage—or into the subjacent tissue, which may produce too vigorous a response, resulting in excessive atrophy of the skin and subcutaneous tissues surrounding the lesion and in depigmentation of darker skins. Both of these adverse responses may improve spontaneously in 6-12 months, but not necessarily completely. Cushing symptoms have even been reported with the overuse of corticosteroids for scar management. Topical corticosteroid therapy is of little or no value for substantial scarring but may have some place with more superficial scarring, such as in the case of dermabrasion.
At present, surgical excision is used only in conjunction with intralesional corticosteroid therapy. Excision is usually confined to the larger lesions in which steroid therapy would exceed safe dosages. (The wound is injected at the time of surgery and then postoperatively according to the schedule recommended above.) Care should be taken so that surgical incisions are not extended into the normal skin around the keloid, since the growth of a new keloid may occur in these scars.
et al.: A new uniform protocol of combined corticosteroid injections and ointment application reduces recurrence rates after surgical keloid/hypertrophic scar excision. Dermatol Surg 2012;38(6):693.
TA: HMG-CoA reductase inhibitors (statins) reduce hypertrophic scar formation in a rabbit ear wounding model. Plast Reconstr Surg 2012;129(2):252e.
TA: Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg 2008;32(1):82.
R: Laser CO2 versus radiotherapy in treatment of keloid scars. Cosmet Laser Ther 2012;14(2):94.
E: Mechanical receptor-related mechanisms in scar management: a review and hypothesis. Plast Reconstr Surg 2010;126(2):426.
Contraction is a normal process of wound healing. Contracture, on the other hand, is a pathologic end stage related to the process of contraction. Generally, contractures develop when wounds heal with too much scarring and contraction of the scar tissue results in distortion of surrounding tissues. Although scar contractures can occur in any flexible tissue, such as the eyelids or lips, contractures usually occur across areas of flexion, such as the neck, axilla, or antecubital fossa. The contracted scar brings together the structures on either side of the joint space and prevents active or even passive extension. Exceptions to this pattern of flexion contractures are extension contractures of the toes and metacarpophalangeal (MP) joints of the digits. Contraction is thought to occur via smooth muscle contractile elements in myofibroblasts, but the mechanism is not well understood. In one vertical abdominal scar, there may be an area of normal scar formation and an area of hypertrophic scar formation with visible contracture. Contracture can occur in response to the presence of foreign material such as Silastic or saline breast implants. Overall, there is a 10% incidence of some form of breast capsular contracture. Myofibroblasts are thought to play an important role, but the actual cause is not known.
Recent studies have shown that subacute infections with bacteria such as Staphylococcus epidermidis create a biofilm and are likely causes of implant contracture and implant complications.
The best treatment of contractures is prevention. Incisions should not be made at right angles to flexion creases or should be reoriented by Z-plasties. Wounds in areas of flexion can be covered with flaps or grafted early with thick split-thickness or full-thickness grafts to stop the process of contraction. Such wounds should also be splinted in a position of extension during healing and for 2-3 weeks after healing is complete. Vigorous physical therapy may also be helpful.
Once a contracture is established, stretching and massage are rarely beneficial. Narrow bands of contracture may be excised and released with one or more Z-plasties. Larger areas must be incised from the medial to the lateral axis across the flexion surface and completely opened up to full extension. The resulting defect can be extensive and must be resurfaced with a skin flap or skin graft. In recurrent contractures a fasciocutaneous flap is the treatment of choice. If a skin graft is used, the area must be splinted in extension for approximately 2 weeks after the graft has healed. Less aggressive surgery is likely to result in recurrence.
et al.: The impact of triamcinolone
acetonide in early breast capsule formation in a rabbit model. Aesthetic Plast Surg
HR: The role of acellular dermal matrix in the treatment of capsular contracture. Clin Plast Surg 2012;39(2):127.
et al.: A long-term follow-up study of acellular derm matrix with thin autograft in burn patients. Ann Plast Surg 2011;67(4):346.
Tumors of the skin are by far the most common of all tumors in humans. They arise from each of the histologic structures that make up the skin—epidermis, connective tissue, gland, muscle, and nerve elements—and are correspondingly numerous in variety. Skin tumors are classified as benign, premalignant, and malignant.
The many benign tumors that arise from the skin rarely interfere with function. Since most are removed for aesthetic reasons or to rule out malignancy, they are quite commonly treated by the plastic surgeon. The majority are small and can be simply excised under local anesthesia following the principles of elliptical excision and wound closure discussed above. General anesthesia may be necessary for larger lesions requiring excision and repair by skin grafts or flaps or those occurring in young children.
When the diagnosis is not in doubt, most superficial lesions (seborrheic keratoses, verrucae, squamous cell papillomas) can be treated by simple techniques such as electrodesiccation, curettage and electrodesiccation, cryotherapy, and topical cytotoxic agents.
Seborrheic keratoses are superficial noninvasive tumors that originate in the epidermis. They appear in older people as multiple slightly elevated yellowish, brown, or brownish-black irregularly rounded plaques with waxy or oily surfaces. They are most commonly found on the trunk and shoulders but are frequently seen on the scalp and face.
Because the lesion is raised above the epidermis, treatment usually consists of shave excision. Care should be exercised to avoid shaving a melanoma because if that is done, it will interfere with the determination of the depth of invasion by the Breslow or Clark classifications. If there is any question about a pigmented lesion, it is preferable to do an excisional biopsy rather than to shave it.
Verrucae (common warts) are usually seen in children and young adults, commonly on the fingers and hands. They appear as round or oval elevated lesions with rough surfaces composed of multiple rounded or filiform keratinized projections. They may be skin colored or gray to brown.
Verrucae are caused by a virus and are autoinoculable, which can result in multiple lesions around the original growth or frequent recurrences following treatment if the virus is not completely eradicated. They may disappear spontaneously.
Treatment by electrodesiccation is effective but is frequently followed by slow healing. Repeated applications of bichloroacetic acid, liquid nitrogen, or liquid CO2 are also effective. Surgical excision alone is not recommended, because the wound may become inoculated with the virus, leading to recurrences in and around the scar. However, surgical excision in conjunction with electrodesiccation, can be an effective form of treatment.
Recurrence remains a common problem; therefore, it is reasonable to delay treatment of asymptomatic lesions for several months to determine if they will disappear spontaneously.
JJ: Benign and premalignant lesions CME. Plast Reconstr Surg 2010;125(5):188e.
A. Epidermal Inclusion Cyst
Although sebaceous cyst is the commonly used term, these lesions more properly should be called epidermal inclusion cysts because they are composed of thin layers of epidermal cells filled with epithelial debris. True cysts arising from sebaceous epithelial cells are uncommon.
Epidermal inclusion cysts are soft to firm, usually elevated, and are filled with an odorous cheesy material. Their most common sites of occurrence are the scalp, face, ears, neck, and back. They are usually covered by normal skin, which may show dimpling at the site of skin attachment. They frequently present as infected cysts.
Treatment consists of surgical excision.
Dermoid cysts are deeper than epidermal cysts. They are not attached to the skin but frequently are attached to or extend through underlying bony structures. They may appear in many sites but are most common around the nose or the orbit, where they may extend to meningeal structures, necessitating CT scans to determine their extent.
Treatment is by surgical excision, which may necessitate sectioning of adjacent bony structures.
Nevocellular nevi are groups of cells of probable neural crest origin that contain melanocytes that form melanin more rapidly upon stimulation than surrounding tissue. These cells migrate to different parts of the skin to give different types of nevi. They may also be distinguished by their clinical presentation.
Junctional nevi are well-defined pigmented lesions appearing in infancy. They are usually flat or slightly elevated and light brown to dark brown. They may appear on any part of the body, but most nevi seen on the palms, soles, and genitalia are of the junctional type. Histologically, a proliferation of melanocytes is present in the epidermis at the epidermal-dermal junction. It was formerly thought that these nevi give rise to malignant melanoma and that all junctional nevi should be excised for prophylactic reasons. However, most investigators now feel that the risk is very slight. If there is no change in their appearance, treatment is unnecessary. Any change such as itching, inflammation, darkening in color, halo formation, increase in size, bleeding, or ulceration calls for immediate treatment.
Surgical excision is the only safe method of treatment.
Intradermal nevi are the typical dome shaped, sometimes pedunculated, fleshy to brownish pigmented moles that are characteristically seen in adults. They frequently contain hairs and may occur anywhere on the body.
Microscopically, melanocytes are present entirely within the dermis and, in contrast to junctional nevi, show little activity. They are rarely malignant and require no treatment except for aesthetic reasons.
Surgical excision is nearly always the treatment of choice. Pigmented nevi should never be treated without obtaining tissue for histologic examination.
Compound nevi exhibit the histologic features of both junctional and intradermal nevi in that melanocytes lie both at the epidermal-dermal junction and within the dermis. They are usually elevated, dome shaped, and light-brown to dark-brown in color.
Because of the presence of nevus cells at the epidermal-dermal junction, the indications for treatment are the same as for junctional nevi. If treatment is indicated, surgical excision is the method of choice.
D. Spindle Cell-Epithelioma Cell Nevi
These nevi, formerly called benign juvenile melanomas, appear in children or adults. They vary markedly in vascularity, degree of pigmentation, and accompanying hyperkeratosis. Clinically, they simulate warts or hemangiomas rather than moles. They may increase in size rapidly, but the average lesion reaches only 6-8 mm in diameter, remaining entirely benign without invasion or metastases. Microscopically, the lesion can be confused with malignant melanoma by the inexperienced pathologist. The usual treatment is excisional biopsy.
Blue nevi are small, sharply defined, round, dark blue or grayish-blue lesions that may occur anywhere on the body but are most commonly seen on the face, neck, hands, and arms. They usually appear in childhood as slowly growing, well-defined nodules covered by a smooth, intact epidermis. Microscopically, the melanocytes that make up this lesion are limited to (but may be found in all layers of) the dermis. An intimate association with the fibroblasts of the dermis is seen, giving the lesion a fibrotic appearance not seen in other nevi. This, together with extension of melanocytes deep into the dermis, may account for the blue rather than brown color.
Treatment is not mandatory unless the patient desires removal for aesthetic reasons or fear of cancer. Surgical excision is the treatment of choice.
Unlike most nevi arising from melanocytes, giant hairy nevi are congenital. They may occur anywhere on the body and may cover large areas. They may be large enough to cover the entire trunk (bathing trunk nevi). They are of special significance for several reasons: (1) Their large size is especially deforming from an aesthetic standpoint; (2) they show a predisposition for developing malignant melanoma; and (3) they may be associated with neurofibromas or melanocytic involvement of the leptomeninges and other neurologic abnormalities.
Microscopically, a varied picture is present. All of the characteristics of intradermal and compound nevi may be seen. Neurofibromas may also be present within the lesion. Malignant melanoma may arise anywhere within the large lesion; the reported rate of occurrence ranges from 1% to as high as 13.7% in one study. Malignant melanoma with metastases rarely arises in childhood or infancy.
The only full treatment is complete excision and skin grafting. Large lesions may require excision and grafting in stages. Some lesions are so large that excision is not possible and the most effective approach is using tissue expansion in combination with flaps. Split-thickness excision or dermabrasion has been successful when done in infancy.
The use of cultured epithelial autografts has been advocated for extensive lesions associated with multiple satellite nevi. Additionally, some have reported the use of laser photothermolysis of pigmented lesions that cannot be excised with favorable reconstructive outcomes. However, there is still concern over malignant transformation of remaining melanocytes, and close long-term follow-up is recommended when laser ablation is used.
B: Surgical management of large and giant congenital pigmented nevi of the lower extremity. Plast Reconstr Surg 2008;121(5):1674.
Vascular Tumors & Vascular Malformations
Our understanding of vascular tumors and vascular malformations has evolved a great deal since the description by Mulliken and Glowacki in 1982 of the biologic classification of vascular anomalies based on their endothelial properties. In this way, infant hemangiomas appear within the first 3 weeks of life and have a proliferative endothelium that grows rapidly at first and commonly involutes usually in the first few years of life. Vascular malformations, on the other hand, have stable endothelium, grow proportionally with the child, and persist into adulthood. They can be associated with various complications, such as skeletal abnormalities, ischemia, coagulopathy, heart failure, and death.
Glucose transporter isoform 1 (GLUT1) has recently been discovered to be a distinguishing feature among various forms of vascular anomalies. It is an immunohistochemical marker that is normally restricted to endothelial cells with blood-tissue barrier function as in the brain and placenta. North and colleagues retrospectively studied specimens from vascular tumors for GLUT1. Specimens from infantile hemangiomas were universally positive. In contrast, biopsies of other vascular anomalies, including rapidly involuting congenital hemangioma (RICH), noninvoluting congenital hemangioma (NICH), pyogenic granuloma, granulation tissue, vascular malformations, and tufted angioma and kaposiform hemangioendothelioma, were all negative. In addition to providing an early diagnostic assay for hemangiomas, GLUT1 can be useful in research and in trying to explain the pathophysiology.
The International Society for the Study of Vascular Anomalies proposed a classification in 1996 based on the pioneering work of Mulliken and Glowacki. It is now the most widely accepted among specialists and in the literature. Clear classification is vitally important so that proper communication regarding diagnosis and treatment can be established. Table 41–3 shows that classification.
Table 41–3.International Society for the Study of Vascular Anomalies Classification. |Favorite Table|Download (.pdf) Table 41–3. International Society for the Study of Vascular Anomalies Classification.
Rapidly involuting congenital hemangioma (RICH)
Noninvoluting congenital hemangioma (NICH)
Capillary (or venular) malformation (port wine stain)
A. Hemangiomas of Infancy (Involuting Hemangioma)
Involuting hemangiomas are the most common tumors that occur in childhood and constitute at least 95% of all the hemangiomas that are seen in infancy and childhood. They are true neoplasms of endothelial cells but are unique among neoplasms in that they undergo complete, spontaneous involution.
Typically, they are present shortly after birth or appear during the first 2-3 weeks of life. They grow at a rather rapid rate for 4-6 months; then growth ceases and spontaneous involution begins. Involution progresses slowly but approximately 50% are involuted by 5 years of age and 70% by age 7. Involuting hemangiomas appear on all body surfaces but are seen more often on the head and neck. They are seen twice as often in girls as in boys and show a predisposition for fair-skinned individuals.
Three forms of infantile hemangiomas are seen: (1) superficial, (2) combined superficial and deep (mixed), and (3) deep. Superficial involuting hemangiomas appear as sharply demarcated, bright-red, slightly raised lesions with an irregular surface that has been described as resembling a strawberry. Combined superficial and deep involuting hemangiomas have the same surface characteristics, but beneath the skin surface, a firm bluish tumor is present that may extend deeply into the subcutaneous tissues. Deep involuting hemangiomas present as deep blue tumors covered by normal-appearing skin.
Hemangiomas are the result of angiogenic dysfunction. Multiple markers of angiogenesis are increased during the proliferative flow, including flibroblast growth factor, vascular endothelial growth factor, and matrix metalloproteinases. These all decrease with the exception of basic fibroblast growth factor during the involution phase.
As the phase of involution progresses, the histologic picture changes, with the solid fields of endothelial cells breaking up into closely packed, capillary-sized, vessel-like structures composed of several layers of soft endothelial cells supported by a sparse fibrous stroma. These vascular structures gradually become fewer and spaced more widely apart in a loose, edematous fibrous stroma. The endothelial cells continue to disappear, so that by the time involution is complete the histologic picture is entirely normal, with no trace of endothelial cells.
Treatment is not usually indicated, since the appearance following spontaneous regression is nearly always superior to the scars that follow surgical excision. Surgical excision of lesions that involve important structures such as the eyelids, nose, or lips may sometimes be necessary in order to avoid serious functional disturbances of vision and airway. Complete excision is usually not necessary.
When treatment is indicated, multiple options have been described including cryotherapy, corticosteroids, interferon and chemotherapy. More recently, the use of the beta blocker propranolol has shown to halt hemangioma progression and dramatically shorten the involution time. Usual doses are from 2-3 mg/kg/day, and infants are usually admitted for 24 hours upon starting this therapy for cardiac monitoring. Although the actual mechanism of action remains unknown, it most likely has to do with downregulation of angiogenic growth factors. It has shown such good results that some institutions are using this as a first-line treatment for complicated infantile hemangiomas.
Ulceration is a painful and dangerous complication with hemangiomas that can develop in approximately 8% of patients. This may be accompanied by infection, which is treated by the use of compresses of warm saline or potassium permanganate and by the application of antimicrobial powders and creams. Bleeding from the ulcer can occur if there is constant irritation and inflammation. When it occurs, gentle pressure should be applied. In some situations, such as the perianal region, specific measures may be needed to keep the area clean and dry including a diverting colostomy combined with judicious serial excision. In rare cases, the platelet trapping of these lesions leads to the clinical picture of disseminated intravascular coagulopathy called Kasabach-Merritt syndrome.
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et al.: Propranolol vs corticosteroids for infantile hemangiomas: a multicenter retrospective analysis. Arch Dermatol[Archives of Dermatology Full Text]
P: Comparison of efficacy of intralesional bleomycin and oral propanolol in management of hemangiomas. Plast Reconstr Surg 2012;129(4):733e.
B. Congenital Hemangiomas (RICH and NICH)
Congenital hemangiomas, as their name implies, are present at birth. They have undergone their rapid growth phase in utero, and in contrast to hemangiomas of infancy, they do not undergo rapid growth during the first 4-6 months of life. Because of their natural history they are divided into two subtypes: RICH and NICH. RICH are more common than NICH, although both are rare. The diagnosis of RICH is confirmed when they rapidly involute by 6-10 months of age. The NICH anomalies, on the other hand, persist into adulthood and may require surgical excision or other ablative measures. Imaging may be helpful (sonography or MRI) in order to evaluate location and extent of the tumor. Both RICH and NICH are GLUT1 negative in contrast to hemangiomas of infancy.
C. Capillary Malformations
Capillary malformations (ie, port-wine stains) are by far the most common of the vascular malformations. They may involve any portion of the body but most commonly appear on the face as flat patchy lesions that are reddish to purple in color. When present on the face, they are located in areas supplied by the sensory branches of the fifth (trigeminal) cranial nerve. They usually start off light red in color yet have a propensity to deepen in color, as their name implies. Their growth is variable, but they persist into adulthood if not treated and become raised and thickened with nodules appearing on the surface (Figure 41–10).
46-year-old white female with untreated port-wine stain of left face. A. Preoperative. B. Status postexcision of facial portion and reconstruction with free tissue transfer.
Microscopically, port-wine stains are made up of thin-walled capillaries that are arranged throughout the dermis. The capillaries are lined with mature, flat endothelial cells. In the lesions that produce surface growth, groups of round proliferating endothelial cells and large venous sinuses are seen.
Results following treatment of the port-wine stain were uniformly disappointing. Because most lesions occur on the face or neck, patients seek treatment for aesthetic reasons, but as they progress in thickness and nodularity, they can become functionally disabling and can bleed spontaneously. The simplest method of treatment is camouflaging. Unfortunately, this is difficult because the port-wine stain is darker than the surrounding lighter skin, and it does not affect the natural history of the lesion.
Superficial methods of treatment such as dry ice, liquid nitrogen, electrocoagulation, and dermabrasion have been tried but are ineffective unless they destroy the upper layers of the skin, which can produce severe scarring.
Radiation therapy, including the use of x-rays, radium, thorium X, and grenz x-rays, is to be condemned. If it is administered in doses high enough to destroy the vessels involved, it also destroys the surrounding tissues and the overlying skin, and the cancer incidence after radiotherapy for skin hemangioma increases.
The best treatment to date for early and intermediate port-wine stains is with the pulsed dye laser. The pulsed dye laser produces a light with a specific wavelength of 585 or 595 nanometers. The method of treatment is termed selective photothermolysis. The beam is selectively absorbed by red-pigmented material such as hemoglobin in the blood vessels of the lesion. This produces selective heat destruction of these structures, and the treated area becomes whiter. When started early, these treatments can be very effective. Multiple treatments are necessary to obtain a satisfactory result. In darker and more advanced nodular lesions, the laser is less effective because of the thickness of the lesion and the hyperpigmentation that may develop.
If the lesion is small, surgical excision with primary closure is possible. Unfortunately, most lesions are large. In the case of long-standing untreated lesions, surgical excision may be necessary, followed by skin grafting, locoregional flaps, or at times free tissue transfer. Certain fast-growing capillary or primarily arterialized hemangiomas have been managed successfully with superselective embolization, either alone or in conjunction with surgery. This is performed under fluoroscopic control and with an expert team. There have been reports of slough of large portions of the face as a result of misdirected embolizations.
Venous malformations (otherwise known as cavernous hemangiomas) are bluish or purplish lesions that are usually elevated. They may occur anywhere on the body but, like other vascular lesions, are more common on the head and neck. They are composed of mature, fully formed venous structures that are present in tortuous masses that have been described as feeling like a bag of worms.
Venous malformations are usually present at birth but do not usually grow except to keep pace with normal body growth. In many cases, growth occurs later in life and may interfere with normal function.
Microscopically, venous malformations are made up of large, dilated, closely packed vascular sinuses that are engorged with blood. They are lined by flat endothelial cells and may have muscular walls like normal veins.
Treatment is difficult. In only a few cases is the lesion small enough or superficial enough to permit complete surgical excision. Most lesions involve deeper structures—including muscle and bone—so that complete excision is impossible without radical surgery. Since most lesions are no more than aesthetic problems, radical surgery is rarely indicated. Occasionally, the injection of sclerosing agents directly into the venous channels may lead to some involution or may make surgical excision easier. Great care must be used so that areas of overlying skin do not slough.
E. Arteriovenous Malformations
Arteriovenous malformations are high-flow lesions having a direct connection between an artery and a vein, bypassing the capillary bed.
Arteriovenous malformations are typically recognized at birth but are misdiagnosed as capillary malformations or involuting hemangiomas. Periods of rapid growth are found after trauma and during periods when the body is under the influence of hormonal changes.
Clinical diagnosis can be confirmed with color Doppler examination, but this does not give information concerning extent of the lesion or relation to surrounding structures. This information can be obtained via MRI or angiography, which has the additional benefit of therapeutic embolization.
Treatment for arteriovenous malformations is based on clinical stage of the lesion. Smaller arteriovenous malformations can be primarily resected. Larger, more diffuse arteriovenous malformations are best managed with superselective arterial embolization followed by surgical resection 24-48 hours after embolization in order to minimize intraoperative blood loss.
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PREMALIGNANT SKIN LESIONS
Actinic (Solar) Keratoses
Actinic keratoses are the most common of the precancerous skin lesions. They usually appear as small, single or multiple, slightly elevated, scaly or warty lesions ranging in color from red to yellow, brown, or black. Because they are related to sun exposure, they occur most frequently on the face and the backs of the hands in fair-skinned Caucasians whose skin shows evidence of actinic elastosis.
Microscopically, actinic keratoses consist of well-defined areas of abnormal epithelial cells limited to the epidermis. Approximately 15%-20% of these lesions become malignant, in which case invasion of the dermis as squamous cell carcinoma occurs.
Since the lesions are limited to the epidermis, superficial treatment in the form of curette and electrodesiccation or the application of chemical agents such as liquid nitrogen, phenol, bi- or trichloroacetic acid, or fluorouracil is curative. The application of fluorouracil (5-FU) cream is of particular benefit in preventive treatment in that it destroys lesions of microscopic size—before they can be detected clinically—without causing damage to uninvolved skin.
Chronic Radiation Dermatitis & Ulceration
There are two distinct types of radiation dermatitis. The first and most common follows the acute administration of relatively high dosages of ionizing orthovoltage radiation over relatively short periods—almost always for the treatment of cancer. Dermatitis is characterized by an acute reaction that begins near the third week of therapy, when erythema, blistering, and sloughing of the epidermis start to occur. Burning and hyperesthesia are commonly present. This initial reaction is followed by scarring characterized by atrophy of the epidermis and dermis along with loss of skin appendages (sweat glands, sebaceous glands, and hair follicles). Marked fibrosis of the dermis occurs, with gradual endarteritis and occlusion of the dermal and subdermal vessels. Telangiectasia of the surface vessels is seen, and areas of both hypopigmentation and hyperpigmentation occur.
The second type of radiation dermatitis follows chronic exposure to low doses of ionizing radiation over prolonged periods. It is usually seen in professional personnel who handle radioactive materials or administer x-rays or in patients who have been treated for dermatologic conditions such as acne or excessive facial hair. Therefore, the face and hands are most commonly involved. The acute reaction described above does not usually occur, but the same process of atrophy, scarring, and loss of dermal elements occurs. Drying of the skin becomes more pronounced, and deepening of the skin furrows is typically present. Fortunately, this second type of radiation dermatitis is rarely seen today.
In both types of radiation dermatitis, late changes such as the following may occur: (1) the appearance of hyperkeratotic growths on the skin surface, (2) chronic ulceration, and (3) the development of either basal cell or squamous cell carcinoma. Ulceration and cancer, however, are seen much less commonly in the first type of radiation dermatitis than in the second. When malignant growths appear, basal cell carcinomas are seen more frequently on the face and neck and squamous cell carcinomas more frequently on the hands and body.
Newer radiotherapeutic methods using megavoltage and electron beam techniques have a sparing effect on the skin. However, marked scarring and avascularity of deeper, more extensive areas may present more difficult problems.
Surgical excision is the treatment of choice. Excision should include all of the irradiated tissue including the area of telangiectasia, whenever possible, and the defect should be covered with an appropriate axial or musculocutaneous flap to provide a new blood supply.
Primary wound closure is feasible for only the smallest lesions, and even so, at some risk. Free-skin grafting is usually unsuccessful because of the damage to the vascular supply of the subcutaneous structures. Adjacent random flaps are unreliable because they depend on blood supply from the surrounding irradiated area.
1. Intraepidermal Carcinoma
Intraepidermal carcinoma includes Bowen disease and erythroplasia of Queyrat.
Bowen disease is characterized by single or multiple, brownish or reddish plaques that may appear anywhere on the skin surface but often on covered surfaces. The typical plaque is sharply defined, slightly raised, scaly, and slightly thickened. The surface is often keratotic, and crusting and fissuring may be present. Ulceration is not common but when present suggests malignant degeneration with dermal invasion.
Histologically, hyperplasia of the epidermis is seen, with pleomorphic malpighian cells, giant cells, and atypical epithelial cells that are limited to the epidermis.
Treatment of small or superficial lesions consists of total destruction by curette and electrodesiccation or by any of the other superficially destructive methods (cryotherapy, cytotoxic agents). Excision and skin grafting are preferred for larger lesions and for those that have undergone early malignant degeneration and invasion of the dermis.
Erythroplasia of Queyrat is almost identical to Bowen disease both clinically and histologically but is confined to the glans penis and the vulva, where the lesions appear as red, velvety, irregular, slightly raised plaques. Treatment is as described for Bowen disease.
Basal cell carcinoma is the most common skin cancer. The lesions usually appear on the face and are more common in men than in women. Since exposure to ultraviolet rays of the sun is a causative factor, basal cell carcinoma is most commonly seen in geographic areas where there is significant sun exposure and in people whose skin is most susceptible to actinic damage from exposure (ie, fair-skinned individuals with blue eyes and blond hair). It may occur at any age but is not common before age 40.
The growth rate of basal cell carcinoma is usually slow but nearly always steady and insidious. Several months or years may pass before the patient becomes concerned. Without treatment, widespread invasion and destruction of adjacent tissues may occur, producing massive ulceration. Penetration of the bones of the facial skeleton and the skull may occur late in the course. Basal cell carcinomas rarely metastasize, but death can occur because of direct intracranial extension or erosion of major blood vessels.
Typical individual lesions appear as small, translucent or shiny (“pearly”) elevated nodules with central ulceration and rolled, pearly edges. Telangiectatic vessels are commonly present over the surface, and pigmentation is sometimes present. Superficial ulceration occurs early.
A less common type of basal cell carcinoma is the sclerosing or morphea carcinoma, consisting of elongated strands of basal cell cancer that infiltrate the dermis, with the intervening corium being unusually compact. These lesions are usually flat and whitish or waxy in appearance and firm to palpation—similar in appearance to localized scleroderma. They are particularly difficult to treat because it is difficult to clinically predict the extent of the margins of growth.
The superficial erythematous basal cell cancer (“body basal”) occurs most frequently on the trunk. It appears as reddish plaques with atrophic centers and smooth, slightly raised borders. These lesions are capable of peripheral growth and wide extension but do not become invasive until late.
Pigmented basal cell carcinomas may be mistaken for melanomas because of the large number of melanocytes present within the tumor. They may also be confused with seborrheic keratoses.
There are several methods of treating basal cell carcinoma. All may be curative in some lesions, but no one method is applicable to all. The special features of each basal cell cancer must be considered individually before proper treatment can be selected.
Because most lesions occur on the face, aesthetic and functional results of treatment are important. However, the most important consideration is whether or not therapy is curative. If the basal cell carcinoma is not eradicated by the initial treatment, continued growth and invasion of adjacent tissues will occur, resulting not only in additional tissue destruction but also in invasion of the tumor into deeper structures, making cure more difficult. Adequate treatment of basal cell carcinoma by different modalities achieves a cure rate of approximately 95%.
The principal methods of treatment are curettage and electrodesiccation, surgical excision, and radiation therapy. Chemosurgery, topical chemotherapy, and cryosurgery are not often used but may have value in selected cases.
A. Curettage and Electrodesiccation
Curettage plus electrodesiccation is the usual method of treatment for small lesions. After infiltration with suitable local anesthetic, the lesion and a 2-3 mm margin of normal-appearing skin around it are thoroughly curetted with a small skin curette. The resultant wound is then completely desiccated with an electrosurgical unit to destroy any tumor cells that may not have been removed by the curette. The process is then repeated once or twice if necessary. The wound is left open and allowed to heal secondarily.
Surgical excision, following the principles outlined earlier in this chapter, offers many advantages in the treatment of basal cell carcinoma: (1) Most lesions can be quickly excised in one procedure. (2) Following excision, the entire lesion can be examined by the pathologist, who can determine if the tumor has been completely removed. (3) Deep infiltrative lesions can be completely excised, and cartilage and bone can be removed if they have been invaded. (4) Lesions that occur in dense scar tissue or in other poorly vascularized tissues cannot be treated by curettage and desiccation, radiation therapy, or chemosurgery, since healing is poor. Excision and flap coverage may be the only method for treatment in these conditions. (5) Recurrent lesions in tissues that have been exposed to maximum safe amounts of radiation can be excised and covered.
Small- to moderate-sized lesions can be excised in one stage under local anesthesia. The visible and palpable margins of the tumor are marked on the skin with marking ink. The width of excision is then marked 3-5 mm beyond these margins. If the margins of the basal cell carcinoma are vague, the width of excision will have to be wider to ensure complete removal of the lesion. The lines of incision are drawn around the lesion as a circle. This tissue is excised, taking care to leave a margin of normal-appearing subcutaneous tissue around the deep margins of the tumor. Frozen sections may be obtained at the time of excision to aid in determining whether tumor-free margins have been obtained. This is minimized with experience. It is better to err on the side of removing more normal tissue than necessary rather than to risk including tumor at the margins. Closure of the wound is accomplished in the direction of minimal skin tension, usually along the skin lines. The dog-ears are removed appropriately.
Wounds resulting from the excision of some moderate-sized tumors and nearly all large tumors may require reconstruction of function and appearance with the use of local, regional, and free flaps. This can nearly always be performed in one stage with good frozen section control.
The disadvantages of surgical excision are as follows: (1) Certain large excisions and reconstruction require specialized training and experience to master the surgical techniques. (2) Whereas curettage and desiccation may be performed in the office, surgical excision often requires specialized facilities. (3) In lesions with vague clinical margins, an excessive amount of normal tissue may have to be excised to ensure complete removal even with the use of frozen section verification. (4) Reconstruction may need to wait until permanent pathologic diagnosis and margins are available in cases involving deep or specialized structures.
To overcome some of these objections, Mohs described a new technique in 1941 that allows for serial excisions and microscopic examination of chemically fixed tissue. Newer developments have obviated the cumbersome fixation techniques, but it may still take several hours to scan an area for suspected malignant cells. The procedure is nevertheless quite useful for recurrent lesions and in areas in which maximal preservation is desirable. Nonetheless, there are no prospective comparative studies to indicate that the microscopically controlled removal of tumor by the Mohs technique, which amounts to excision of the lesion with serial review by fresh frozen section, is superior to surgical excision. An additional problem is that there is no quality control because the excising physician is also the one who evaluates the pathology slides. Many of the more extensive lesions treated with the Mohs technique require complex reconstruction to rebuild noble structures that have needed resection.
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RL: Metastatic basal cell carcinoma in the era of hedgehog signaling pathway inhibitors. Cancer 2012 Nov 1 ;118(21):5310–9.
X-ray therapy is as effective as any other in the treatment of basal cell carcinoma. Its advantages are as follows: (1) Structures that are difficult to reconstruct, such as the eyelids, tear ducts, and nasal tip, can be preserved when they are invaded by but not destroyed by tumor. (2) A wide margin of tissue can be treated around lesions with poorly defined margins to ensure destruction of nondiscernible extensions of tumor. (3) It may be less traumatic than surgical excision to elderly patients with advanced lesions. (4) Hospitalization is not necessary.
The disadvantages are as follows: (1) Only well-trained, experienced physicians can obtain good results. (2) Expensive facilities are necessary. (3) Improperly administered radiation therapy may produce severe sequelae, including scarring, radiation dermatitis, ulceration, and malignant degeneration. (4) In hair-bearing areas, epilation will result. (5) It may be difficult to treat areas of irregular contour (eg, the ear and the auditory canal). (6) Repeated treatments over a period of 4-6 weeks may be necessary.
X-ray therapy should not be used in patients under age 40 except in unusual circumstances, and it should not be repeated in patients who have failed to respond to radiation therapy in the past.
3. Squamous Cell Carcinoma
Squamous cell carcinoma is the second-most common cancer of the skin in light-skinned racial groups and the most common skin cancer in darkly pigmented racial groups. As with basal cell carcinoma, sunlight is the most common causative factor in whites. The most common sites of occurrence are the ears, cheeks, lower lip, and backs of the hands. Other causative factors are chemical and thermal burns, scars, chronic ulcers, chronic granulomas (tuberculosis of the skin, syphilis), draining sinuses, contact with tars and hydrocarbons, and exposure to ionizing radiation. When a squamous cell carcinoma occurs in a burn scar, it is called a Marjolin ulcer. This lesion may appear many years after the original burn. It tends to be aggressive, and the prognosis is poor.
Because exposure to the sun is the greatest stimulus for the production of squamous cell carcinoma, most of these lesions are preceded by actinic keratosis on areas of the skin showing chronic solar damage. They may also arise from other premalignant skin lesions and from normal-appearing skin.
The natural history of squamous cell carcinoma may be quite variable. It may present as a slowly growing, locally invasive lesion without metastases or as a rapidly growing, widely invasive tumor with early metastatic spread. In general, squamous cell carcinomas that develop from actinic keratoses are more common and are of the slowly growing type, whereas those that develop from Bowen disease, erythroplasia of Queyrat, chronic radiation dermatitis, scars, and chronic ulcers tend to be more aggressive. Lesions that arise from normal-appearing skin and from the lips, genitalia, and anal regions also tend to be aggressive.
Early squamous cell carcinoma usually appears as a small, firm erythematous plaque or nodule with indistinct margins. The surface may be flat and smooth or may be verrucous. As the tumor grows, it becomes raised and, because of progressive invasion, becomes fixed to surrounding tissues. Ulceration may occur early or late but tends to appear earlier in the more rapidly growing lesions.
Histologically, malignant epithelial cells are seen extending down into the dermis as broad, rounded masses or slender strands. In squamous cell carcinomas of low-grade malignancy, the individual cells may be quite well differentiated, resembling uniform mature squamous cells having intercellular bridges. Keratinization may be present, and layers of keratinizing squamous cells may produce typical round “horn pearls.” In highly malignant lesions, the epithelial cells may be extremely atypical; abnormal mitotic figures are common; intercellular bridges are not present; and keratinization does not occur.
As with basal cell carcinomas, the method of treatment that will eradicate squamous cell carcinomas and produce the best aesthetic and functional results varies with the characteristics of the individual lesion. Factors that determine the optimal method of treatment include the size, shape, and location of the tumor as well as the histologic pattern that determines its aggressiveness.
The mainstay of treatment is surgery. Radiation has also been used in some circumstances. Since basal cell carcinomas are relatively nonaggressive lesions that rarely metastasize, failure to eradicate the lesion may result only in local recurrence. Although this may result in extensive local tissue destruction, there is rarely a threat to life. Aggressive squamous cell carcinomas, on the other hand, may metastasize to any part of the body, and failure of treatment may have fatal consequences. For this reason, total eradication of each lesion is the imperative goal of treatment.
The use of sentinel lymph node biopsy (SLNB) is usually reserved for those patients with a high risk squamous cell cancer or when the lesion is larger than 2 cm. This procedure maps the first node basin that any disease would travel to if metastatic. Palpable nodes of any type are a contraindication for SLNB.
et al.: Implications of a positive sentinel node in oral squamous cell carcinoma. Head Neck 2012 Nov;34(11):1580–1585.
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V: Nonmelanoma skin cancer. J Cutan Aesthet Surg 2012;5(1):3.
The plastic surgeon is often involved in emergency room assessment and treatment of soft tissue injuries. Many aspects of wound management must be considered in even a relatively simple facial laceration.
Careful analysis of the soft tissue injury should include (1) the type of wound or wounds (abrasion, contusion, etc); (2) the cause of injury; (3) the age of the injury; (4) the location of injured tissues; (5) the degree of contamination of the injured area before, during, and after trauma; (6) the nature and extent of associated injuries; and (7) the general health of the patient (eg, any chronic or acute illnesses or any allergies; any medications being taken).
The location of the wound must be noted because different healing characteristics are present in various types of skin. The face and scalp are highly vascular and therefore resist infection and heal faster than other areas, but there are many important structures in and around the face, and scars and defects are noticeable. Skin of the trunk, upper arms, and thighs is fairly thick and heals more slowly than facial or scalp skin and is more susceptible to infection. Scarring is less noticeable. The hands are a critical area because there are important structures near the surface, and the destruction caused by infection can be devastating. The lower legs are a particular problem area because the relatively poor blood supply can cause skin loss, and infection is more likely to occur.
The type of wound must be determined so that proper treatment can be given. Contusions and swelling require ice packs for 24 hours, rest, and elevation. Abrasions should be cleaned and dressed in a sterile manner as for a skin graft donor site or must be washed daily until a dry scab forms or healing takes place. Ground-in dirt or gravel must be entirely scrubbed out or picked out with a small blade within 24 hours after injury, or foreign material will be sealed in and traumatic tattooing will result. Extensive local anesthesia may be required to accomplish this. Imbedded particulate matter from an explosion must be removed in a similar manner. Hematomas may be treated with ice bags and pressure until stable. Evacuation is then indicated if vital structures such as the ear or nasal septal cartilage are in danger of being injured or destroyed. Lacerations over bony prominences and various types of cuts require special care that will be detailed below. Treatment must be meticulous if optimal results are to be achieved. Puncture wounds and bites are notoriously innocuous in appearance but may result in severe destruction or tetanus or gas gangrene. Antibiotic coverage, irrigation, open treatment, and observation are indicated. Most bites on the face, however, can be cleaned and safely closed. Wounds that create flaps of skin or avulsions are difficult to manage. Careful debridement and judicious use of full-thickness or split-thickness grafts from the avulsed tissue are recommended. Timing is the first factor to consider.
Wound contamination can be caused by bacteria on the surface of the wounding agent, such as rust on a nail or saliva on a tooth, or bacteria that enter the wound when the skin is broken. Bacteria driven into tissue become more established as time passes, and it is therefore important to know the age of the wound at the time of the presentation for treatment. Other injuries associated with cuts almost always take precedence in treatment. In general, wounds other than those on the face or scalp should not be closed primarily if they occurred 8-12 hours or longer before presentation unless they were caused by a very clean agent and have been covered by a sterile bandage in the interim. Delayed primary closure as described previously is an excellent and safe alternative. Nearly any facial wound up to 24 hours old can be safely closed with careful debridement, irrigation, and antibiotic coverage.
The surgeon must decide whether or not antibiotic treatment is indicated. In general, wounds treated appropriately and early do not call for antibiotic therapy. Antibiotics should be given for wounds with delayed presentation or those for which treatment is delayed by choice (eg, wounds with known contamination; wounds in compromised patients, such as very young or old persons, debilitated persons, or persons with general ill health; wounds in areas where infection may have serious consequences, such as the lower legs and the hands; and wounds in persons in whom bacteremia might have serious sequelae, such as those with prosthetic heart valves or orthopedic appliances). Antibiotics should be started before debridement and closure. Only a few days of coverage are necessary—usually until the wound is checked at 2-3 days and found to be free of infection. Penicillin or a substitute is appropriate for wounds involving the mouth, such as through-and-through lip lacerations and bites. Other wounds are usually contaminated by Staphylococcus aureus, and an antibiotic effective for penicillin-resistant S. aureus is therefore appropriate. If gram-negative or anaerobic contamination is suspected, wound closure is risky, and hospitalization of the patient for treatment with parenteral antibiotics should be considered. Tetanus prophylaxis should be routinely given for patients who have not received current immunizations or who have wounds likely to lead to tetanus. Guidelines for this are detailed in Chapter 8.
Anesthesia is an important part of adequate soft tissue wound care and closure. Local anesthesia with either 0.5% or 1% lidocaine with epinephrine 1:200,000 or 1:100,000 is recommended for all wounds. Smaller amounts of lidocaine and epinephrine may be used in areas of appendages, such as earlobes, toes, and the penis. The injection may be given through the wound edge before debridement and irrigation for maximum patient comfort. Complete epinephrine vasoconstrictor effect occurs within 7 minutes. Overdose of epinephrine and lidocaine injection into vessels or use of the drugs in patients sensitive to these agents should be avoided.
The importance of irrigation cannot be overstated. Over 90% of bacteria in a recently sustained and superficially contaminated wound can be eliminated by adequate irrigation. Ideally, a physiologic solution such as lactated Ringer solution or normal saline should be forcefully ejected from a large syringe with a 19-gauge needle or from other equipment designed for this purpose such as a water-jet apparatus. The wound is irrigated once to remove surface clots, foreign material, and bacteria and is then debrided and irrigated again. Detergents and antiseptic solutions are toxic to exposed tissue and should not be used.
Debridement must include removal of all obviously devitalized tissues. In special areas such as the eyelids, ears, nose, lips, and eyebrows, debridement must be done cautiously, since the tissue lost by debridement may be difficult to replace. Where tissues are more abundant, such as in the cheek, chin, and forehead areas, debridement may be more extensive. Small irregular or ragged wounds in these areas can be excised completely to produce clean, sharply cut wound edges which, when approximated, will produce the finest possible scar. Because the blood supply in the face is plentiful, damaged tissues of questionable viability should be retained rather than debrided away. The chances for survival are good.
Following adequate anesthesia, debridement, and irrigation, the wound is ready for final assessment and closure. Lighting must be adequate, and appropriate instruments should be available. The patient and the surgeon must be positioned comfortably. The skin surrounding the wound is prepared with an antiseptic solution, and the area is draped. A final check of the depth and extent of the wound is made, and vital structures are inspected for injury. Hemostasis must be achieved by use of epinephrine, pressure, cautery, or suture ligature. Important structures in facial wounds include the parotid duct, lacrimal duct, and branches of the facial nerve. These should be repaired in the operating room by microsurgical techniques.
Layers of tissue—usually muscle—in the depth of the wound should be closed first with as few absorbable sutures as possible, since sutures are foreign material within the wound. If possible, dead space should be closed with judicious use of fine absorbable sutures. If dead space cannot be closed, external pressure or small drains are sometimes effective. Skin closure should begin at the most important points of the laceration (eg, the borders of the ears and nose; the vermilion border or margins of the lip; the margins of the eyebrow [which should never be shaved]; and the scalp hairline). Subcuticular sutures are very helpful. Skin edges can be approximated without tension or strangulation with 5-0 or 6-0 monofilament suture material as outlined earlier under wound closure.
Complicated lacerations, such as complex stellate wounds or avulsion flaps, often heal with excessive scarring. Because of the associated subcutaneous tissue injury, U-shaped or trap-door avulsion lacerations almost always become unsightly as a result of wound contracture. Small lacerations of this type are best excised and closed in a straight line initially; larger flaps that must be replaced usually require secondary revision. Extensive loss of skin is generally best treated by initial split-thickness skin grafting followed later by secondary reconstruction. Primary attempts to reconstruct with local flaps may fail because of unsuspected injury to these adjacent tissues. The decision to convert avulsed tissues to free grafts that may not survive and thus delay healing requires sound surgical judgment.
Small- or moderate-sized closures on the face may be dressed with antibiotic ointment alone. The patient may cleanse the suture lines with hydrogen peroxide to clear away crusts and dirt and then reapply the ointment. Elsewhere, closures benefit from the protection of a sterile bandage. Pressure dressings are useful in preventing hematoma formation and severe edema that may result in poor wound healing. Dressings should be changed early and the wound inspected for hematoma or signs of infection. Hematoma evacuation, appropriate drainage, and antibiotic therapy based on culture and sensitivity studies may be required. Removal of sutures in 3-5 days, followed by splinting of the incision with sterile tape, will minimize scarring from the sutures themselves.
The final result of facial wound repair depends on the nature and location of the wounds, individual propensity to scar formation, and the passage of time. A year or more must often pass before resolution of scar contracture and erythema results in maximum improvement. Only after this time, a decision can be made regarding the desirability of secondary scar revision.
In wounds involving the major joints, the extracapsular soft tissue and the intracapsular structures should be considered individually to assess accurately the magnitude of the injury and to provide a prognosis. Open joint injuries that are single penetrating and without extensive soft tissue damage permit uncomplicated joint and wound closure. Injuries that are single or multiple penetrations with extensive soft tissue disruption (flaps, avulsions, degloving) often require secondary operations to attain closure. In injuries that show open periarticular fractures with extension through the adjacent intra-articular surface and with associated nerve or vascular injury requiring repair, the cornerstone for successful management is debridement, antibiotic therapy properly timed and performed, joint closure, and aggressive treatment of the bony injury. Newer techniques such as free-tissue transfer can expedite wound care, decrease morbidity, and spare some limbs from amputation.
Because of the aesthetic and functional importance of the face, fractures of the facial bones—though rarely life threatening—are best treated by surgeons who have extensive experience with facial injuries and reconstruction. Operation is most successful when performed in the acute setting, usually within the first week, because reconstruction becomes much more difficult if surgery is delayed.
Facial bone fractures are usually caused by trauma from a blunt instrument, such as a fist or club, or by violent contact with the steering wheel, dashboard, or windshield during an automobile accident. Particularly in the latter case, the patient should be assessed for associated injuries. For example, cervical spine injuries are present in up to 12% of automobile accident patients and should be treated or stabilized before facial bone injuries are attended to. Injuries to the brain, eyes, chest, abdomen, and extremities must also be assessed and may require earlier treatment.
The diagnosis of facial fractures is made primarily on clinical examination. Ideally, the examination should be done immediately so that swelling will not obscure the findings. The mechanism and the line of direction of injury are important. If conscious, the patient should be asked about previous facial injuries, areas of pain and numbness, whether the jaw opens properly and the teeth come together normally, and whether vision in all quadrants is normal.
Most facial fractures can be palpated, or at least the abnormal position of bones can be noted. Beginning along the mandibular rims, one can feel for irregularities of the facial bones. The dental occlusion is noted. With bimanual palpation, placing the thumbs inside the mouth, one can elicit bony crepitus if there is an associated fracture. The maxilla and midface can be rocked forward and backward between the thumb and the index finger in the presence of a midfacial fracture. Nasal fractures may be detected by palpation. Irregularities and step-offs along the infraorbital border, lateral orbital rim, or zygomatic arch regions indicate a depressed zygomatic fracture.
Radiologic studies are additional aids to the proper diagnosis of facial fractures. Rarely is a significant fracture seen on x-ray that is not also clinically evident. Helpful views include the Waters and submentovertex projections and oblique views of the mandible. The Panorex view of the mandible is very useful to look at the condyles. CT scans of facial bones, with appropriate biplanar and 3D reconstructions so that bones can be viewed through several planes, have essentially supplanted regular radiographs in the workup of the facially injured patient. They are helpful in assessing the extent of fractures, in particular, in more posterior areas such as the ethmoid area, medial and inferior orbit, pterygoid plates, and base of the skull.
The bones of the nose are the most commonly fractured facial bones. Next in frequency are the mandible, the zygomatic-malar bones, and the maxilla.
Fractures may affect the nasal bones, cartilage, and septum. Fractures occur in two patterns, caused by lateral or head-on trauma.
With lateral trauma, the nasal bone on the side of the injury is fractured and displaced toward the septum, the septum is deviated and fractured, and the nasal bone on the side away from the injury is fractured and displaced away from the septum, so that the upper part of the nose, as a whole, is deviated. Depending on the degree of violence, one or more of these displacements will be present, and the degree of comminution is variable.
Head-on trauma gives rise to telescoping and saddling of the nose and broadening of its upper half as a result of the depression and splaying of the fractured nasal bones. This of course produces severe damage to the septum, which usually buckles or actually suffers a fracture. The diagnosis of a fractured nose is made on clinical grounds alone, and x-rays are unnecessary except for medical-legal reasons.
Nasal fractures requiring reduction should be treated with a minimum of delay, for they tend to become fixed in the displaced position in a few days. The surgical approach depends on whether the fracture has resulted in deviation or collapse of the nasal bones. Local anesthesia is preferred; either topical tetracaine or cocaine intranasally or lidocaine for infiltration of the skin can be used. The nasal bones may be disimpacted with intranasal forceps or a periosteal elevator and aligned by external molding or pressure. Collapsed nasal fractures can be repositioned with Walsham nasal forceps, introduced into each nostril and placed on each side of the septum, which is then elevated to its proper position. A septal hematoma should be recognized and drained to prevent infection and subsequent necrosis of the cartilaginous septum with associated collapse of the entire nose. Compound fractures of the nose require prompt repair of the skin wound and, if possible, early reduction of the displaced nasal bones.
External splinting, which is essentially a protective dressing, and intranasal packing using nonadhering gauze are appropriate after reduction. The intranasal packing provides support for the septum in its reduced position and helps prevent development of a hematoma. It also provides counterpressure for the external splint immobilizing the nasal bones and prevents them from collapsing. The packing is usually removed within 48 hours.
In severe comminuted nasal fractures, the medial canthal ligaments, which are easily felt by applying lateral traction to the upper eyelid, may have dislodged. If they have been avulsed, they should be reattached in position to prevent late deformities. For these severe fractures involving the entire naso-orbital and ethmoid complex, the coronal approach, which offers wide exposure, allows for proper anatomic reduction of all small nasal fragments as well as repositioning of the canthal ligaments and correction and elevation of the telescoped bone fragments at the root of the nose and glabella.
The lacrimal apparatus is commonly disrupted in these injuries and should be repaired and stented appropriately.
Mandibular fractures are most commonly bilateral, generally occurring in the region of the mid body at the mental foramen, the angle of the ramus, or at the neck of the condyle. A frequent combination is a fracture at the mental region of the body with a condylar fracture on the opposite side. Displacement of the fragments results from the force of the external blow as well as the pull of the muscles of the floor of the mouth and the muscles of mastication. The diagnosis is suggested by derangement of dental occlusion associated with local pain, swelling, and often crepitation upon palpation. Appropriate x-rays confirm the diagnosis. Special views of the condyle, including tomograms, may be required. Sublingual hematoma and acute malocclusion are usually diagnostic of a mandibular fracture.
Restoration of functional dental occlusion is the most important consideration in treating mandibular fractures. In patients with an adequate complement of teeth, arch bars or interdental wires can be placed. Local nerve block anesthesia is preferable for this procedure, though certain patients may require general anesthesia. Intermaxillary elastic traction will usually correct minor degrees of displacement and bring the teeth into normal occlusion by overcoming the muscle pull. When the fracture involves the base of a tooth socket with suspected devitalization of the tooth, extraction of the tooth should be considered. Particularly in the incisor region, such devitalized teeth may be a source of infection, leading to the development of osteomyelitis and nonunion of the fracture.
Patients with more severe mandibular injuries require anatomic reduction and fixation of the fracture by the open, direct technique. These include compound, comminuted, and unfavorable fractures. An unfavorable fracture is one that is inherently unstable because muscle pull distracts the fracture segments. In this situation, intermaxillary fixation alone is insufficient. Edentulous patients also benefit from the open technique, although proper dentures or dental splints are useful to maintain normal occlusion.
Metal wire fixation of fractured segments and intermaxillary fixation for 6 weeks was a proven and popular method of fracture treatment. The more recent resurgence in popularity of the screw-plate system is due to a number of advantages over wiring. The screw plate usually achieves rigid fixation in three dimensions, providing adequate stability; it eliminates the need for intermaxillary fixation in most cases; it is useful in complex, comminuted fractures; and it is quite easy to use after familiarity with the technique has been acquired.
With bilateral parasymphyseal fractures, anterior stabilization of the tongue may be lost, so that it may fall back and obstruct the airway. Anterior stabilization and splinting must be accomplished early in these cases.
Open reduction is rarely advised in condylar fractures; simple intermaxillary fixation for 4-6 weeks is sufficient. Indications for open reduction are severely displaced fractures, which may prevent motion of the mandible because of impingement of the coronoid process on the zygomatic arch. In children, the fracture may destroy the growth center of the condyle, resulting in maldevelopment of the mandible and gross distortion.
ZYGOMATIC & ORBITAL FRACTURE
Fractures of the zygomatic bones may involve just the arch of the zygomatic bone or the entire body of the zygoma (the malar eminence) and the lateral wall and floor of the orbit. The so-called tripod fracture characteristically occurs at the frontozygomatic and zygomaticomaxillary sutures as well as at the arch. It should be referred to as a tetrapod fracture because the anterior or posterior buttress of the maxilla is also involved in the fracture. Displacement of the body of the zygoma results in flattening of the cheek and depression of the orbital rim and floor.
Important diagnostic signs are subconjunctival hemorrhage, disturbances of extraocular muscle function (which may be accompanied by diplopia), and loss of sensation in the upper lip and alveoli on the involved side as a result of injury to the infraorbital nerve. Reduction of a displaced zygomatic fracture is seldom an emergency procedure and may be delayed until the patient’s general condition is satisfactory for anesthesia. Local anesthesia will suffice only for reduction of fractures of the zygomatic arch. More extensively displaced fractures usually require general anesthesia. At least two-point fixation with direct interosseous wiring is necessary for these fractures. Here again, delicate miniplates have been used with success, providing anatomic reduction and rigid fixation.
Simple depressed fractures of the zygomatic arch can best be elevated using the Gillies technique. Through a temporal incision above the hairline, an instrument is passed beneath the superficial layer of the deep temporalis fascia and under the arch and the body of the zygoma. The fracture can also be elevated percutaneously with a hook or screw in conjunction with overlying palpation to achieve accurate reduction. If the fracture is complex or comminuted, as is often the case with high-velocity injuries, repair through a coronal scalp approach may be necessary to obtain an anatomic and stable result.
Extensive disruption should be suspected in conjunction with the zygomatic fracture when significant diplopia and enophthalmos and posterior displacement of the globe are present. Orbital fat and extraocular muscles may herniate through the defect and become entrapped, giving rise to the signs and symptoms. A “blowout” fracture is similar disruption of the orbital floor due to blunt trauma to the globe but not associated with a fracture of the zygoma or orbital rim. Treatment in both cases demands exploration, reduction of herniated contents, and repair of the floor. The most direct approach is through a lower lid subciliary incision, which provides excellent visualization. A buccal transantral (Caldwell-Luc) approach can be used, and blind antral packing for support has been described. This is quite hazardous, because bony spicules may be pushed into the ocular globe and perhaps cause injury or blindness. In cases of extensive communication or loss of bony fragments of the floor, use of local autogenous bone or cartilage as a scaffold may be performed. At times, in cases of extensive injuries to the floor, alloplastic material in the form of titanium mesh may be necessary.
Even with careful anatomic reduction and repair of the orbital floor, ocular problems—particularly enophthalmos—may persist, possibly due to an undiagnosed fracture, especially a medial ethmoidal blowout fracture. These can be properly evaluated with CT scanning. Treatment requires reduction and repair of the defect. The injury can at times cause ischemia of herniated soft tissue and subsequent atrophy and scarring. This may result in enophthalmos, which is almost impossible to resolve completely.
Maxillary fractures range in complexity from partial fractures through the alveolar process to extensive displacement of the midfacial structures in conjunction with fractures of the frontonasal bones and orbital maxillary region and total craniofacial separation. Hemorrhage and airway obstruction require emergency care, and in severe cases, tracheostomy is indicated. Mobility of the maxilla can be elicited by palpation in extensive fractures. “Dish-face” deformity of the retrodisplaced maxilla may be disguised by edema, and careful x-ray studies are necessary to determine the extent and complexity of the midfacial fracture. Treatment may have to be delayed because of other severe injuries. A delay of as long as 10-14 days may be safe before reduction and fixation, but the earliest possible restoration of maxillary position and dental occlusion is desirable to prevent late complications.
In the case of unilateral fractures or bilateral fractures with little or no displacement, splinting by intermaxillary fixation for 4 weeks may suffice. Fractures are usually displaced inferiorly or posteriorly and require direct surgical disimpaction and reduction and proper fixation with appropriate plates and screws. Early reduction may help control bleeding, as torn, stretched vessels are allowed to reestablish their normal tension. In certain severe cases, external traction may be necessary. Manipulation is directed toward restoring normal occlusion and maintaining the reduction with intermaxillary fixation to the mandible in association with direct plate fixation. Complicated fractures may require external fixation utilizing a head cap and intraoral splints in conjunction with multiple surgical incisions for direct plate fixation. Coexisting mandibular fractures usually necessitate open reduction and fixation at the same time.
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CONGENITAL HEAD & NECK ANOMALIES
Cleft lip, cleft palate, and combinations of the two are the most common congenital anomalies of the head and neck. The incidence of facial clefts has been reported to be 1 in every 650-750 live births, making this deformity second only to clubfoot in frequency as a reported birth defect.
The cleft may involve the floor of the nostril and lip on one or both sides and may extend through the alveolus, the hard palate, and the entire soft palate. A useful classification based on embryologic and anatomic aspects divides the structures into the primary and the secondary palate. The dividing point between the primary palate anteriorly and the secondary palate posteriorly is the incisive foramen. Clefts can thus be classified as partial or complete clefts of the primary or secondary palate (or both) in various combinations. The most common clefts are left unilateral complete clefts of the primary and secondary palate and partial midline clefts of the secondary palate, involving the soft palate and part of the hard palate.
Most infants with cleft palate present some feeding difficulties, and breast-feeding may be impossible. As a rule, enlarging the openings in an artificial nipple or using a syringe with a soft rubber feeding tube will solve difficulties in sucking. Feeding in the upright position helps prevent oronasal reflux or aspiration. Severe feeding and breathing problems and recurrent aspiration are seen in Pierre Robin sequence, in which the palatal cleft is associated with a receding lower jaw and posterior and cephalic displacement of the tongue, obstructing the naso-oropharyngeal airway. This is a medical emergency and is a cause of sudden infant death syndrome (SIDS). Nonsurgical treatment includes pulling the tongue forward with an instrument and laying the baby prone with a towel under the chest to let the mandible and tongue drop forward. Insertion of a small (No. 8) nasogastric tube into the pharynx may temporarily prevent respiratory distress and may be used to supplement the baby’s feedings. Placement of an acrylic obturator or appliance has proved quite successful in alleviating the breathing difficulties by bringing the tongue down and permitting a better nasal airway. Several surgical procedures that bring the tongue and mandible forward have been described but should be employed only when conservative measures have been tried without success. Recently, the use of distraction of the mandible has shown some beneficial effects. However, it should be done with great caution in the neonate.
Surgical repair of cleft lip is not considered an emergency. The optimal time for operation can be described as the widely accepted “rule of 10.” This includes body weight of 10 lb (4.5 kg) or more and a hemoglobin of 10 g/dL or more. This is usually at some time after the tenth week of life. In most cases, closure of the lip will mold distortions of the cleft alveolus into a satisfactory contour. In occasional cases in which there is marked distortion of the alveolus, such as in severe bilateral clefts with marked protrusion of the premaxilla, preliminary maxillary orthodontic treatment may be indicated. This may involve the use of carefully crafted appliances or simple constant pressure by use of an elastic band.
General endotracheal anesthesia via an orally placed endotracheal tube is the anesthetic technique of choice. A variety of techniques for repair of unilateral clefts have evolved over many years. Earlier procedures ignored anatomic landmarks and resulted in a characteristic “repaired harelip” look. The Millard rotation advancement operation that is now commonly used for repair employs an incision in the medial side of the cleft to allow the Cupid’s bow of the lip to be rotated down to a normal position. The resulting gap in the medial side of the cleft is filled by advancing a flap from the lateral side. This principle can be varied in placement of the incisions and results in most cases in a symmetric lip with normally placed landmarks. Bilateral clefts, because of greater deficiency of tissue, present more challenging technical problems. Maximum preservation of available tissue is the underlying principle, and most surgeons prefer approximation of the central and lateral lip elements in a straight line closure, rolling up the vermilion border of the lip (Manchester repair).
Secondary revisions are frequently necessary in the older child with a repaired cleft lip. A constant-associated deformity in patients with cleft lip is distortion of the soft tissue and cartilage structures of the ala and dome of the nose. These patients often present with deficiency of growth of the structures of the midface. This has been attributed to intrinsic growth disturbances and to external pressures from the lip and palate repairs. Some correction of these deformities, especially of the nose, can be done at the initial lip operation. More definitive correction is done after the cartilage and bone growth is more complete. These may include scar revisions and rearrangement of the cartilage structure of the nose. Recent approaches involve degloving of the nasal skin envelope with complete exposure of the abnormal cartilage framework. These are then rearranged in proper position with or without additional grafts. Maxillary osteotomies (Le Fort I with advancement) will substantially correct the midfacial depression. A tight upper lip due to severe tissue deficiency can be corrected by a two-stage transfer of a lower lip flap known as an Abbe flap.
In utero repair of cleft lip deformities has recently become a topic of discussion. In utero repair affords the potential to provide a scarless repair and correct the primary deformity. Furthermore, scarless fetal lip and palate repairs may prevent the ripple effect of postnatal scarring with its resultant secondary dentoalveolar and midface growth deformities. While these suggestions make in utero repair attractive, the risk of fetal loss remains high. Preterm labor is a major complication and one that is directly related to the large hysterotomy required for fetal exposure. Due to the great risks associated with it, intrauterine fetal surgery is still largely reserved for severe malformations that cannot be helped significantly by postnatal intervention.
Palatal clefts may involve the alveolus, the bony hard palate, or the soft palate, singly or in any combination. Clefts of the hard palate and alveolus may be either unilateral or bilateral, whereas the soft palate cleft is always midline, extending back through the uvula. The width of the cleft varies greatly, making the amount of tissue available for repair also variable. The bony palate, with its mucoperiosteal lining, forms the roof of the anterior mouth and the floor of the nose. The posteriorly attached soft palate is composed of five paired muscles of speech and swallowing.
Surgical closure of the cleft to allow for normal speech is the treatment of choice. The timetable for closure depends on the size of the cleft and any other associated problems. However, the defect should be closed before the child undertakes serious speech, usually before age 2. Closure at 6 months usually is performed without difficulty and also aids in the child’s feeding. If the soft palate seems to be long enough, simple approximation of the freshened edges of the cleft after freeing of the tissues through lateral relaxing incisions may suffice. If the soft palate is too short, a pushback type of operation is required. In this procedure, the short soft palate is retrodisplaced closer to the posterior pharyngeal wall utilizing the mucoperiosteal flaps based on the posterior palatine artery.
Satisfactory speech following surgical repair of cleft palate is achieved in 70%-90% of cases. Significant speech defects usually require secondary operations when the child is older. The most widely used technique is the pharyngeal flap operation, in which the palatopharyngeal space is reduced by attaching a flap of posterior pharyngeal muscle and mucosa to the soft palate. This permits voluntary closure of the velopharyngeal complex and thus avoids hypernasal speech. Various other kinds of pharyngoplasties have been useful in selected cases.
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et al.: Is presurgical nasoalveolar molding therapy more effective in unilateral or bilateral cleft lip-cleft palate patients? Plast Reconstr Surg 2011;127(3):1263.
et al.: One-stage cleft repair outcome at age 6- to 18- years – a comparison to the Eurocleft study data. Br J Oral Maxillofac Surg 2012 Dec;50(8):762–768.
et al.: Primary alveolar bone grafting and gingivoperiosteoplasty or gingivomucoperiosteal flap at the time of 1-stage repair of unilateral cleft lip and palate. J Craniofac Surg 2009;20(2):1729.
These are congenital deformities of the hard and soft tissues of the head. Particular problems of the brain, eye, and internal ear are treated by the appropriate specialist. The craniofacial surgeon often needs the collaboration of these specialists when operating on such patients.
Serious craniofacial anomalies are relatively rare, although mild forms often go undiagnosed or are accepted as normal variants. A classification is therefore difficult, although many have been proposed. Tessier has offered a numerical classification based on clinical presentation. He considers a cleft to be the basis of the malformation, which involves both hard and soft tissues (Figure 41–11).
Tessier classification of craniofacial clefts. The numbering system goes from 0 to 14, and the skeletal defects mimic the soft tissue presentation.
Other classifications are based on embryologic and etiologic features. With greater understanding and continued investigation, classification efforts will no doubt be more satisfactory.
There are well-known chromosomal and genetic aberrations as well as environmental causes that can lead to craniofacial deformity. The cause in most cases, however, is unknown. Arrest in the migration and proliferation of neural crest cells and defects in differentiation characterize most of these deformities. We describe some of the more common ones in brief terms.
Crouzon syndrome (craniofacial dysostosis) and Apert syndrome (acrocephalosyndactyly) are closely related, differing in the extremity deformities present in the latter. Both are autosomal dominant traits with variable expression. Both present with skull deformities due to premature closure of the cranial sutures. The cranial sutures most affected will determine the type of skull deformity. Exophthalmos, midfacial hypoplasia, and hypertelorism are also features of these two syndromes.
The facial organs and tissues proceed in great measure from the first and second branchial arches and the first branchial cleft. Disorders in their development lead to a spectrum of anomalies of variable severity. Treacher-Collins syndrome (mandibulofacial dysostosis) is a severe disorder characterized by hypoplasia of the malar bones and lower eyelids, colobomas, and antimongoloid slant of the palpebrae. The mandible and ears are often quite underdeveloped. The presentation is bilateral and is an autosomal dominant trait. A unilateral deformity known as hemifacial microsomia presents with progressive skeletal and soft tissue underdevelopment. The Goldenhar variant of hemifacial microsomia is a severe form associated with upper bulbar dermoids, notching of the upper eyelids, and vertebral anomalies.
Some of these patients show mental retardation, but in most cases, intelligence is not affected. The psychosocial problems are serious and most often related to how the patients look. Within the past two decades, craniofacial surgery has progressed so that previously untreatable deformities can now be corrected. With the anatomic work of Le Fort as a basis—and guided by the incomplete attempts of Gillies and others—Paul Tessier, in the late 1960s, proposed a set of surgical techniques to correct major craniofacial deformities. Two basic concepts soon emerged from his work: (1) Large segments of the craniofacial skeleton can be completely denuded of their blood supply, repositioned, and yet survive and heal; and (2) the eyes can be translocated horizontally or vertically over a considerable distance with no adverse effect on vision. The tendency today is to operate at approximately 6-9 months of age (if possible not later than a year) for cranial vault remodeling and fronto-orbital advancement.
A bicoronal scalp incision is utilized to expose the skull and facial bones with an intracranial or extracranial approach. The cut bones are then reshaped, repositioned, and fixed with a combination of wires or miniplates and screws. The latter have the advantage of rigid fixation and less need to maintain large movements with bone grafts. Autogenous inlay and onlay bone grafts can be used to improve contour. The entire operation is usually completed in one stage, and complications are surprisingly few. Miniplates have been used extensively in the last few years. In infants, fixation with absorbable suture material or the newer absorbable plates and screws have provided effective and stable fixation. They commonly resorb at 6-9 months. They do not interfere with imaging techniques such as CT or MRI, and they seem to have less impairment of craniofacial growth and development.
Craniofacial surgery has improved the treatment not only of major congenital deformities but also of major complex facial fractures, chronic sequelae of trauma, isolated exophthalmos, fibrous dysplasia, and aesthetic facial sculpturing.
Microtia is absence or hypoplasia of the pinna of the ear, with a blind or absent external auditory meatus. The incidence of significant auricular deformity is about one in 8000 births and is usually spontaneous. Ten percent of these defects are bilateral, and boys are afflicted twice or three times as commonly as girls. Because the ear arises from the first and second branchial arches, the middle ear is always involved, and many patients have other disorders of the first and second arches. The inner ear structures are usually spared.
Generally, correction of conductive hearing by an otologist has not been long lasting or helpful, and surgery for this problem is reserved for bilateral cases.
Different techniques have been described that vary in terms of required surgeries as well as technical complexity. The Brent and Nagata techniques are the most commonly used today with the Brent requiring four stages and the Nagata only two. In any case reconstruction of the external ear usually involves a multistage procedure beginning at preschool age. Autogenous rib cartilage or cartilage from the opposite ear is used to construct a framework to replace the absent ear. The cartilage is imbedded under the skin in the appropriate area, and after adjustments are made in local tissue to reposition or recreate the earlobe and conchal cavity, the framework is elevated posteriorly and the resulting sulcus grafted to obtain projection. In cases in which local tissue is poor or unavailable, the neighboring superficial temporalis fascia is dissected and placed over the cartilage framework. This is then skin grafted with adequate tissue.
The opposite (normal) ear is occasionally altered to provide better symmetry. Excellent results have been achieved. Silastic frameworks for ear cartilage have also been used, and although their use eliminates donor site problems, rates of infection and extrusion have been unacceptable. More recently, a porous polyethylene construct has been used with better long-term results. A temporalis fascia flap is rotated to cover the allograft, and then a full-thickness skin graft is placed. They are quite useful in bilateral cases or when sufficient cartilage is not available.
Lesser deformities, such as overly large, prominent, or bent ears, are corrected by appropriate resection of skin and cartilage, “scoring” of the cartilage to alter its curve, and placement sutures to aid in contouring.
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W: Early experience in microtia reconstruction: the first 100 cases. J Plast Reconstr Aesthet Surg 2011;64(4):452.
ANOMALIES OF THE HANDS & EXTREMITIES
The most common hand anomaly is syndactyly, or webbing of the digits. This may be simple, involving only soft tissue, or complex, involving fusion of bone and soft tissue. The fusion may be partial or complete. Surgical correction involves separation and repair with local flaps and skin grafts. Correction should be done before growth disturbance of the webbed digits takes place. Other anomalies, such as extra digits (polydactyly), absence of digits (adactyly), and cleft hand, also exist.
Flexion contractures of the hands or digits may require surgical release and appropriate skin grafting. Congenital ring constriction of the extremities may be associated also with congenital amputation. The ring constrictions are best treated by excision and Z-plasty.
Poland syndrome consists of a variable degree of unilateral chest deformity—usually absence of the pectoralis major muscle—associated with hand symbrachydactyly. The hand deformity is treated according to the severity. The latissimus dorsi muscles can be transposed to replace the absent pectoralis major, simulating the sites of origin and insertion. In more severe cases and in women requiring breast and chest reconstruction, the transverse rectus abdominis island flap can be used to replace the deficit.
HEAD & NECK RECONSTRUCTION
Many of the tumors discussed in Chapter 15 require surgical excision as a primary form of therapy. This often involves removal of large areas of composite tissue, such as the floor of the mouth, the maxilla, part of the mandible, or the lymph-bearing tissue of the neck. Reconstruction after such resections can be very challenging and may require special skill.
A salient advance in the complete treatment of the patient with a head or neck tumor is reconstruction, usually done in the same setting. Free flaps with microvascular techniques are the most appropriate methods even though they require a high level of skill and are time consuming. The free flaps most commonly used following ablative procedures in the head and neck include the anterolateral thigh flap or the radial forearm flap for resurfacing the floor of the mouth and the composite fibular flap, which includes fibula as well as skin, to reconstruct the mandible and the floor of the mouth. For larger defects, judicious use of the rectus abdominis muscle, latissimus dorsi, or other musculocutaneous flaps has also been helpful. For pharyngoesophageal reconstruction, either the tubed radial forearm flap or the free jejunum is most successful.
Since no two surgical resections for tumor in the head and neck are identical, the key to effective treatment is preoperative planning. Probable extent of resection, areas that will require preoperative or postoperative radiation therapy, incision and flaps created by neck dissections, and available donor areas must all be carefully assessed. New preoperative techniques are being used that is based off of preoperative CT scanning, such as Pro-Plan. From these scans, templates are created that show exactly where excisions should be made, and for mandibular reconstruction, the size, and bending of the plate can all be done preoperatively.
Useful musculocutaneous flaps in the head and neck are the sternocleidomastoid, platysma, trapezius, pectoralis major, and latissimus dorsi muscles. Useful axial skin flaps can be obtained from the forehead, deltopectoral, and cervicohumeral areas. When these flaps are insufficient or unavailable for the reconstructive needs of the patient, free tissue transfer must be used. Although many flaps have been developed for bone and soft tissue reconstructions, the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap are the most useful free flaps for head and neck reconstruction. Healing is quick, so radiation, if necessary, may be started as early as 1 month after surgery.
FC: One-stage double barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and aesthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg 2008;122(1):143.
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AK: Free microsurgical and pedicled flaps for oncological mandibular reconstruction: technical aspects and evaluation of patient comorbidities. ISRN Surg 2012;2012:792674.
SF: Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg 2012;129(6):1305.
Reconstruction of the female breast after mastectomy is available to all patients in the United States, and new techniques continue to be developed providing women with more options. The insurance carriers now pay for this procedure as part of the treatment for breast cancer, and this includes symmetry surgery of the contralateral breast. Even women with significant defects in the anterior chest wall as a result of radical mastectomy and radiation therapy can undergo reconstructive surgery if they are otherwise appropriate candidates.
Heightened awareness of breast cancer along with well-established screening guidelines has affected surgical treatment of the cancer and, subsequently, approaches to reconstruction of the breast. A skin-sparing, modified radical mastectomy, for example, may allow for an immediate reconstruction with autologous tissue that results in an aesthetically pleasing breast mound. Lumpectomy followed by irradiation, initially indicated for relatively small tumors, has now expanded to larger tumors and may thus result in considerable distortion and concavity in the treated breast. In the appropriate patient, concomitant bilateral reduction mammaplasty may allow for a large lumpectomy while maintaining symmetry.
The methods of reconstruction include the use of saline implants, tissue expanders, autologous tissue, or a combination of these methods. Following mastectomy, simple placement of an implant is usually unsatisfactory except in a few thin patients with relatively small contralateral breasts. The implant is usually placed in the submuscular position, utilizing the remaining pectoralis major muscle and occasionally the serratus anterior muscle for adequate muscle coverage. This results in a firm, rounded type of reconstruction and does not simulate the soft “teardrop” appearance of the normal breast. Even when adequate skin has been saved following a skin-sparing mastectomy, placement of an implant is unsatisfactory because of the high rate of complications due to skin necrosis of the saved overlying skin, which results in exposure of the implant. When doing an immediate reconstruction with implant following a skin-sparing mastectomy, it is preferable to transpose the latissimus dorsi muscle to provide another layer of cover for the implant so that if there is necrosis of the skin from the skin-sparing mastectomy, the implant will not be exposed.
The latissimus dorsi myocutaneous flap is used most often for reconstruction of the breast with an implant. The myocutaneous unit is outlined with a skin island transversely so that the scar will be transverse and covered by the brassiere. The unit is freed up completely except for its insertion at the humerus, thus preserving the neurovascular pedicle. It is transposed as a pendulum through the anterior chest wall. The superior portion of the latissimus dorsi is sutured to the pectoralis major muscle, and the lower edge is secured to the lower skin flap as far down as it will reach. The implant is then inserted, having been covered by the latissimus dorsi inferiorly and by two layers of muscle superiorly—the latissimus dorsi and the pectoralis major. The skin island is utilized in its entirety, if necessary, or is deepithelialized appropriately, maintaining only the skin portion that is needed. This method is most suitable for patients who do not have a large amount of abdominal skin, are relatively thin, and do not object to the use of implants, which sometimes may even be inserted in the opposite breast in an effort to achieve symmetry.
The use of tissue expanders continues to be a popular method of breast reconstruction. The use of acellular dermal matrices (ADM) has made expander results more satisfying. Rather than using muscle and tissue alone to cover the expander, ADM is used to create a sling that replicates the lower pole of a breast. This allows for increased initial fill rates, and a more natural appearing breast. (Figure 41–12) Over a period of 6 weeks to 3 months, the expander is progressively inflated with saline percutaneously. The expander is inflated at least 25% more than the desired volume. A period of time—approximately 3 months—is advisable as a waiting period to prevent the “recall phenomenon,” which is the shrinking that may occur following removal of the expander as it is replaced by a permanent implant. ADM has come under scrutiny though due to increased rates of seroma and other complications associated with its use. Multiple studies have shown this to be true, but it remains difficult to identify the exact patient characteristics that make them more prone to these problems.
A. Reconstructed right breast with ADM in place to recreate lower breast pole B. Close-up of right breast with ADM and pectoralis major interface shown.
The use of radiation therapy has continued to become more commonplace for the treatment of breast cancer. When it is used, autologous tissue is the standard for breast reconstruction. Implant base reconstruction has been shown to have significantly higher complication rates when radiation therapy is involved. The transverse rectus abdominis myocutaneous (TRAM) flap based on the superior epigastric vessel(s) remains the standard for breast reconstruction so that an implant is not required. The incision at the donor site is similar to that of an abdominoplasty operation along the lower abdomen. This method of reconstruction produces the most normal and natural breast in appearance and feel, but it requires a longer operating time as well as a longer period of hospitalization than reconstruction with tissue expanders and implants alone.
If the superior epigastric system has been violated (from surgery or trauma) or if there are other factors that would question the reliability of these vessels to adequately supply the volume and region of tissue required for the reconstruction, the surgeon may favor using the inferior epigastric system and transferring the TRAM as a free flap. Typical recipient vessels are the internal mammary or the thoracodorsal vessels. Again, past surgical history, previous (or planned) radiation, and anatomic variance may dictate reconstructive strategy regarding recipient vessels and whether to use the ipsilateral or contralateral inferior epigastric system.
Because successful breast reconstruction is common, many surgeons have sought to refine autologous reconstruction by decreasing donor site morbidity. Modifications of the free TRAM flap have been made so that the rectus abdominis muscle is mostly spared (muscle-sparing TRAM) or spared in its entirety. This latter technique is referred to as a deep inferior epigastric perforator (DIEP) flap. The same skin territory as the TRAM flap is used; however, the musculocutaneous branches that supply the skin are dissected away from the rectus abdominis muscle. In this manner, the muscle itself is spared and left in situ in an effort to preserve muscular function and reduce abdominal wall weakness. The deep inferior epigastric vessels are then divided, the flap is inset into the thoracic defect, and the flap vessels are anastomosed to recipient vessels along the chest wall. An extension of the DIEP has been the superficial inferior epigastric artery (SIEA) free flap. Although feasible in only a minority of patients, this artery allows for free flap reconstruction that completely avoids any dissection of the rectus muscle. This means minimal abdominal wall complications for the patient.
In addition to reconstruction of the affected breast, many patients undergo procedures that alter the contralateral (noncancerous) breast so that volume and ptosis are comparable. Such symmetry procedures are considered stages in postoncologic breast reconstruction. The nipple-areola complex can also be reconstructed. Current techniques for nipple reconstruction utilize adjacent flaps from the area where the nipple is to be positioned, taking skin and variable amounts of underlying fat if a TRAM flap has been used or elevating skin and lesser amounts of subcutaneous tissue if an implant (with or without the latissimus dorsi flap) was used. The areola may be reconstructed with a full-thickness skin graft followed by tattooing at a later date for color match.
et al.: Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010;126(4):1133.
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LOWER EXTREMITY RECONSTRUCTION
Probably one of the most difficult areas for which to provide wound coverage and closure is the lower extremity, particularly the distal leg and foot areas. Tenuous and unstable skin grafts or poorly vascularized local or cross-leg skin flaps were once the only tissues available for resurfacing of these parts of the body. When large segments of bone were exposed or missing or when infection had become established, these grafts or flaps often were inadequate and amputation was the only recourse. Use of musculocutaneous flaps, and particularly free flaps, has greatly improved coverage in the lower extremities.
Generally, wound problems in the lower leg, ankle, and foot involve orthopedic injuries, such as compound tibial or ankle fractures. Multiple classification systems are used, but the most popular is the Gustilo and the Byrd system. These take into account the degree of fracture as well as tissue loss as well as nerve and arterial involvement.
Treatment depends on the extent of tissue loss and the depth of the wound. Fairly extensive wounds around the knee and upper third of the leg can be reconstructed with a gastrocnemius muscle flap (usually the medial head) and a split-thickness skin graft. Soft tissue defects of the middle third of the leg can be reconstructed in a similar manner by the soleus muscle in many cases. Large middle third and distal third soft tissue defects are more difficult to reconstruct. When they are complicated by extensive bone and soft tissue loss, free tissue transfer may be necessary. Although there are small muscles that end in tendons in the foot, such as the peroneus brevis, flexor hallucis longus, and extensor digitorum muscles, they can provide only limited coverage. If there is a suitable recipient artery remaining in the leg, better coverage is generally provided by a free muscle flap such as the gracilis muscle for small- and medium-sized defects or the latissimus dorsi or rectus abdominis muscle for larger defects.
Large areas of the heel or the sole of the foot are difficult to replace because skin in these regions is specially adapted to bear the weight of the body without shearing or breaking down. Free muscle flaps surfaced with skin grafts have proven to be adequate, but protective sensation is missing. The use of free neurovascular axial skin flaps, such as the inferior gluteal thigh flap and the deltoid flap, may help provide coverage with some gross sensation. Neurosensory flaps—and specifically the sural flap, distally based on one of the lower septocutaneous perforators from the lateral aspect of the leg and supplied by the sural artery, which accompanies the sural nerve—have been used to resurface defects around the ankle and heel. The procedure provides good skin and fascia for a weight-bearing area such as the heel, but it usually does not provide protective sensibility.
Segmental defects of the tibia may be reconstructed with bone grafts or, if the gap is large, free bone flaps such as the contralateral fibula or iliac crest. It is also possible to reconstruct the soft tissue defect and then reconstruct the bony gap with a distraction osteogenesis technique (Ilizarov bone transport). This bone transport method consists of performing a cortical osteotomy proximal to the site of injury and then applying a distraction apparatus, which in effect lengthens the bone 1 mm per day by appropriate adjustment screws. Such lower extremity reconstruction requires a well-coordinated, cooperative effort between the plastic and orthopedic surgeons. While such limb salvage is possible, amputation may be recommended in cases where a constellation of complications are present, such as bony gaps greater than 8 cm, extensive vascular injury, greater than 6 hours of warm ischemia time, an insensate limb, loss of plantar flexion, or an overall medically unstable patient.
Osteomyelitis of the tibia or bones in the foot may be devastating and often uncontrollable. Probably because of poor vascularity in the area, even long-term antibiotic treatment has often failed to control bone infections in the leg. Recently, effective surgical treatment for bone infections has been developed. The bone is surgically debrided and covered with a microvascular free muscle flap such as the gracilis or rectus abdominis muscle. Apparently, the muscle tissue with its excellent blood supply not only covers the exposed bone but assists natural defenses in controlling infection. Antibiotics are also used, but the well-vascularized muscle flap appears to be the deciding factor in control of infection. Reconstruction of bony defects may be accomplished at a later date.
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Pressure sores—often less precisely called bedsores or decubitus ulcers—are another example of difficult wound problems that can be treated by plastic surgery. Pressure sores generally occur in patients who are bedridden and unable or unwilling to change position; patients who cannot change position because of a cast or appliance; and patients who have no sensation in an area that is not moved even though they may be ambulatory. The underlying cause of sores in these patients is ischemic necrosis resulting from prolonged pressure against the soft tissue overlying bone. There is also some evidence that local factors in denervated skin predispose to pressure breakdown because there is atrophy of the skin and subcutaneous tissue.
Absence of normal protective reflexes must be compensated for. Prevention is clearly the best treatment for pressure sores. Casts and appliances must be well padded, and points of pressure or pain should be relieved. Bedridden patients must be turned to a new position at least every 2 hours. Water and air mattresses, sheepskin pads, and foam cushions may help relieve pressure but are not substitutes for frequent turning. The introduction of the flotation bed system, which distributes pressure uniformly over a large surface area, has greatly aided in the management of these patients. The pressure on the skin at any time is less than the capillary filling pressure, avoiding many ischemic problems. Paraplegics should not sit in one position for more than 2 hours. Careful daily examination should be made for erythema, the earliest sign of ischemic injury. Erythematous areas should be freed from all pressure. Electrical stimulations, biomaterials, and growth factors are additional modalities to expedite wound repair, but the results are variable.
Once pressure necrosis is established, it is important to determine whether underlying tissues such as fat and muscle are affected, since they are much more likely than skin to become necrotic. A small skin ulcer may be the manifestation of a much larger area of destruction below. If the area is not too extensive and if infection and abscess due to external or hematogenous bacteria are not present, necrotic tissue may be replaced by scar tissue. Continued pressure will not only prevent scar tissue from forming but will also extend the injury. A surface eschar or skin may cover a significant abscess.
If the pressure sore is small and noninfected, application of drying agents to the wound and removal of all pressure to the area may permit slow healing. Wounds extending down to bone rarely heal without surgery. Infected wounds must be debrided down to clean tissue. The objectives at operation are to debride devitalized tissue, including bone, and to provide healthy, well-vascularized padded tissue as a covering. All of the original tissue that formed the bed of the ulcer must be excised.
When the patient’s nutritional status and general condition of health are optimal, definitive coverage can be performed. Coverage is usually accomplished with a muscle, musculocutaneous, or, sometimes, an axial flap. Well-vascularized muscle appears to help control established low-grade bacterial contamination. The muscle flaps used for the more common bedsores are as follows: greater trochanter: tensor fasciae latae; ischium: gracilis, gluteus maximus, or hamstrings; sacrum: gluteus maximus. Occasionally, it is possible to provide sensibility to the area of a pressure sore with an innervated flap from above the level of paraplegia. The most common example is the tensor fasciae latae flap with the contained lateral femoral cutaneous nerve from L4 and L5, which is used to cover an ischial sore. Rarely, an innervated intercostal flap from the abdominal wall may be used to cover an insensible sacrum. Unfortunately, attempts to provide protective sensibility with sensory flaps have not had good results. The tissue expansion techniques should not be the primary surgery treatment of decubitus ulcers but can be used in difficult cases where available tissue is insufficient to close the wound.
Postoperatively, the donor and recipient areas must be kept free of pressure for 2-3 weeks to allow for complete healing. This puts significant demands on other areas of the body that may be equally at risk or may already have areas of breakdown. The use of the air-fluidized bed has greatly aided such situations.
In spite of excellent padding provided by musculocutaneous flaps, recurrence of pressure sores is still a major problem, because the situation that caused the original breakdown usually still exists. Prevention of sores is even more important for these patients.
K: Protocal management of late-stage pressure ulcers: a 5 year retrospective study of 101 consecutive patients with 179 ulcers. Plast Reconstr Surg 2012;129(4):897.
YT: A reuseable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction. Microsurgery 2012;32(3):189.
B: Trunk, abdomen, and pressure sore reconstruction. Plast Reconstr Surg 2011;128(3):201e.
Aesthetic surgery is an integral part of plastic surgery. In fact, the two terms have become almost synonymous even though aesthetic surgery is only one band in a broad spectrum. Increased interest and curiosity about the specialty results in part from increased demands for its services by an aging population but also from the development of more predictable, lasting, and safer techniques. A number of specialists other than plastic surgeons have also performed and contributed to cosmetic surgery. A skilled surgeon can perform such cosmetic operations safely and with maximum benefit to the patient.
Patient selection is probably as important for success as any other factor. Not all patients are good candidates for aesthetic procedures, and such operations are contraindicated in others. Age or poor general health of the patient may be a reason for delay or avoidance of purely elective procedures. Two other major factors must be considered. The first factor is the anatomic feasibility of the procedure. Can the alterations be made successfully and safely? Which technique will best accomplish the goal? The second factor is the psychologic makeup of the patient. Does the patient fully understand the nature of the proposed procedure and its risks and consequences? Are the patient’s expectations realistic? Cosmetic changes in appearance will generally not save a failing marriage, help to procure a new job, or substantially improve a person’s station in life, and persons with such expectations should not undergo aesthetic surgery. Surgery should be postponed for persons experiencing severe stress, such as is associated with divorce, death of a loved one, or other periods of emotional instability.
The ideal candidate for cosmetic surgery is an adult or mature younger person who has a realistic idea of what is to be accomplished, is not under pressure from others to have the operation done, and does not expect major changes in interpersonal relations or career potential following surgery. Personal satisfaction is a valid reason for seeking aesthetic refinements.
The more common aesthetic procedures are discussed below. Some procedures involve correction of functional problems as well and are therefore not always considered purely cosmetic procedures.
Surgical alterations of nasal structures are done for relief of airway obstruction (usually secondary to trauma) and to reshape the nose because of undesirable characteristics, such as a prominent dorsal hump, bulbous or drooping tip, or overly large size. There is often a combination of problems.
Procedures are generally performed through intranasal incisions. The nasal skin is usually temporarily freed from its underlying bony and cartilaginous framework, so that the framework can be altered by removal, rearrangement, or augmentation of bone or cartilage. The skin is then redraped over the new foundation. The nasal septum and lower turbinate can also be altered to reestablish an open airway. A better understanding of nasal physiology has enabled surgeons to correct internal valve dysfunction by inserting spreader grafts—often following modification of the bony radix of the nose. Spreader grafts are small pieces of cartilage placed next to the septum and under the upper lateral cartilages. They serve to open up the internal valve in somewhat the same way as the external “breathe easy” appliances utilized by athletes.
Surgery can be done under local or general anesthesia; in either case, topical and injectable vasoconstrictors and anesthetic agents are commonly used. Hospitalization may or may not be indicated. Nasal packing is often used for hemostasis and support of the nasal mucosa during initial healing, as incisions are usually only minimally sutured with absorbable sutures. External nasal splints are placed to control swelling and provide some protection, particularly if osteotomy of the nasal bones is performed.
Convalescence requires 10-14 days before most swelling and periorbital ecchymosis subside; however, several months are often required before completely normal sensation returns, and all swelling resolves.
Nasal procedures are very commonly performed, generally quite safe, and usually effective. Complications include bleeding, internal scarring, recurrence of airways obstruction, and irregularities of contour. Infections are rare except with the use of alloplastic nasal implants.
J: Rhinoplasty and bony vault complications. Facial Plast Surg 2012;28(3):303.
The combined effects of gravity, sun exposure, and loss of elasticity due to aging result in varying degrees of wrinkles and sagging of skin along the cheeks, jawline, neck, and elsewhere in the facial area. These natural signs of aging can be removed to a great extent by a facelift procedure. Not all wrinkles can be removed; however, those in the forehead, around the eyes, in the nasolabial area, and around the lips are not significantly corrected without additional procedures.
Rhytidectomy is a major procedure requiring extensive incisions hidden in the scalp and in front of and behind the ears and occasionally in the submental region. The first such operations consisted of freeing up the skin and then stretching it and resuturing as it was drawn cephalad and laterally. This gave a mask-like and unnatural appearance. In the last few years, there has been a significant change in the concept of the facelift procedure, so that now it consists of elevation of the soft tissues—particularly the jowls and malar fat pads—to where they were at a younger age, giving more prominence to the cheek bones and better delineating the jawline. Undermining of the skin is done only to approach the soft tissues to be elevated, and the excess skin is now removed and reapproximated without tension. This approach to the midface has given more natural and lasting results and provides also a 3D type of restoration of the soft tissues, giving a more youthful appearance.
For the double neck, extensive freeing up of the skin over the neck from the jawline down to the hyoid is performed, and the fat overlying the platysmal muscle is removed either by suctioning or directly with scissors. The platysma itself is tightened laterally as well as centrally to provide an effect similar to a hammock that will give a more defined neck and jaw angle.
Drains are used particularly in the neck, as well as a padded circumferential dressing to protect the face and provide light pressure during healing. The introduction of fat aspiration procedures (liposuction) has been adapted to the neck but is not recommended for the face since it may produce abnormal lines (“railroad tracks of demarcation”). In appropriate patients, liposuction in the neck does give fine definition to the chin and jawline and may substantially correct the double chin appearance.
Either local or general anesthesia may be used for this often lengthy (3-4 hours) procedure. Local vasoconstrictors are routinely used.
Complications include hematoma, skin slough, injuries to branches of the facial nerve or greater auricular nerve, scars, and asymmetry. Signs of aging often recur years later.
et al.: A systemic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg 2009;123(6):1819.
Endoscopy has become an integral part of plastic surgery, particularly for procedures involving the face or the breast. Smaller endoscopes are now utilized as well as different methods of achieving a desired optical field other than by distention of natural cavities with fluid or gases. In the face and in the breast, the optical cavity is usually obtained by tractioning the skin with appropriate elevators or sutures.
Endoscopy has been most effective for the forehead, where in appropriate circumstances it has replaced the coronal incision, which goes from ear to ear, peeling the scalp down to the supraorbital rims. By means of endoscopy, the forehead lift becomes a more physiologic operation in that one frees up the forehead skin at the subperiosteal level, dividing the periosteum at the supraorbital rim and then removing the depressors of the eyebrows (the procerus and corrugator muscles in the glabella region), thus allowing the frontalis muscle to act unopposed to elevate the eyebrows. The key to the procedure appears to be the division of the periosteum, which by itself frees up the eyebrows and elevates them for at least 5-10 mm. In addition, removal of the glabellar muscles seems to ameliorate in a lasting way the vertical wrinkles in the glabella region. For suspension of the elevated eyebrows, different methods have been advocated that include soft tissue to bony anchoring, the use of temporary screws in the skull as well as miniplates, or, most simply, by providing external traction tied in between staples with nylon sutures. It appears that it is only necessary to maintain that elevation for a short period of time (3-5 days) until the periosteum reattaches at the higher level.
Endoscopy has also been effectively utilized to do a midfacelift, and this procedure is applicable to younger patients where there is no excess skin in the face or neck and where scars will be unattractive.
Endoscopy is also utilized for the breasts—particularly for insertion of breast implants in the submammary or subpectoral plane through an axillary incision. An endoscope attached to a right-angle retractor allows excellent visualization of the cavity where the implant is to be inserted, and it allows the development of a pocket inferiorly down to—and if necessary below—the submammary fold and also the division of the lower portion of the origin of the pectoralis major muscle from the sternum to permit insertion of a saline implant and to provide acceptable cleavage. Appropriate instruments for dissection as well as hemostasis have been developed for this procedure, which recently has gained in popularity.
Blepharoplasty involves removal of redundant skin of the upper and lower eyelids and removal of periorbital fat protruding through sagging orbital septa. It is done alone or as part of a facelift procedure.
Incisions are made in the upper lids surrounding previously marked redundant skin, which is removed. A subciliary incision is generally used in the lower lids. The orbicularis oculi muscle may be altered if necessary. The periorbital fat compartments are opened, and protruding fat is removed. The extent of redundant skin in the lower lid is gauged, and the skin is resected. External sutures are used. Minimal or no dressing is required.
Local anesthesia in the form of lidocaine with epinephrine is usually adequate. Swelling and ecchymosis subside in 7-10 days, and sutures are removed in 3-4 days.
Complications include bleeding, hematoma formation, epidermal inclusion cysts, ectropion, and asymmetry. Patients are usually satisfied with the results. Recurrence is much less of a problem than with facelift procedures.
In recent years there have been significant changes in the concept of the blepharoplasty procedure. For the upper lids, the change consists of the recognition of senile ptosis due to either disruption or stretching of the levator mechanism. This can be corrected by imbrication of the levator mechanism with sutures.
The lower eyelid operation has undergone even more changes. A general trend has been to do less surgery or dissection but still obtain the same satisfactory results. Less disruption of the orbicularis muscle and orbital septum with “no touch” techniques have become popular. Also, less removal of fat but rather redistribution has gained wider acceptance. The subconjunctival removal of fat has been advocated and is particularly applicable to young patients with congenital fat hernias. The subconjunctival approach is also utilized in conjunction with the laser, which has the effect of tightening the skin of the lower lid and ameliorating the periorbital wrinkles.
Another important concept is the recognition of the proper position of the lower lid, especially the lateral canthal area. A youthful appearance is restored by elevating this to a more normal level.
Aside from procedures related to breast cancer, surgery of the female breast is generally done for one of the following reasons: to increase the size of the breasts (augmentation mammoplasty), to decrease the size of the breasts (reduction mammoplasty), or to lift the breasts (mastopexy). Augmentation, lifting of the breasts, and correction of asymmetry are nearly always done for cosmetic reasons. Reduction of hypertrophied breasts may, however, be done for functional reasons, since such breasts can cause poor posture, back and shoulder pain, and discomfort due to grooves from brassiere straps.
In procedures for augmentation of the breasts, a silicone bag filled with saline solution or silicone is placed beneath the breast tissue in the submammary or subpectoral plane. Incisions are concealed in the periareolar margin, inframammary fold area, or axilla. Dissection is then carried out above or below the pectoralis major muscle, and the implant is placed in the pocket created. Drains are not generally used, and a padded dressing providing light pressure is applied. The subpectoral plane is preferred by most surgeons for augmentation mammoplasty because it does not interfere with mammography, but it does necessitate division of the lower portion of the origin of the pectoralis major muscle up to approximately 3 o’clock in relation to the nipple to provide adequate cleavage.
After a prolonged investigation by the FDA, silicone gel–filled implants have recently become available again in the United States for cosmetic purposes. During the investigation, silicone gel–filled implants were found to be safe; however, long-term data concerning these implants (ie, capsular contracture, deflation and rupture rates) remains unknown. Nevertheless, patients and surgeons now have the opportunity to review the data and choose the type of implant used during breast augmentation.
The procedure can be done on an outpatient basis with local anesthesia, although this may not be satisfactory when subpectoral implants are used. General anesthesia is often used for augmentation procedures.
Although patient satisfaction is excellent in most cases, a significant rate of capsular contracture remains a problem in about 10%. Scar tissue around the implant may contract in variable degrees even in the same patient. Control of this process is difficult even though the best possible environment for healing is provided (ie, appropriate implants are used, infection is controlled, bleeding is not present, debris is removed, and movement is restricted). Implants placed in the subpectoral position appear to be associated with a lesser degree of capsular contracture and less severe deformity if contracture occurs. Deflation of saline implants occurs at a rate of 1% per year.
Other complications include hematoma, infection, exposure of the implant, deflation or rupture of the implant, asymmetry of the breasts, and external scars. Breast function and sensation are usually not altered in any way.
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Mastopexy is another common procedure used for correction of sagging or ptotic breasts. Although some breasts develop in a ptotic manner, most cases are caused by normal relaxation of aging tissues, gravity, and atrophy after pregnancy and lactation. It is not clear whether use of a brassiere alters this process in any significant manner. The degree of deformity is defined by the relationship of the areola to the inframammary fold and the direction of the nipple. A ptotic breast will have a nipple that is below the inframammary line and pointing down towards the toes.
Correction may be done with simultaneous reduction or augmentation. An incision must be made around the areola, and the breast tissue itself is imbricated or, better still, an inferiorly based flap of breast tissue is designed and placed underneath the remnant superior part of the breast and over the pectoralis major muscle, serving as an autoaugmentation as one brings the lateral breast columns together. This procedure gives a more lasting effect than merely decreasing the skin envelope. Attempts at making more lasting corrections of ptosis of the breasts through the periareolar incision, which decreases the scarring, have included wrapping the breast with prosthetic material such as polyglycolic meshes or, more recently, by wrapping it around with segments of pectoralis major muscle.
Nonetheless, significant scarring may occur, particularly around the periareolar incision.
General anesthesia is usually necessary, and recovery from mastopexy may take 7-10 days. Complications include bleeding, infection, tissue loss, altered sensation or loss of function of the nipple and areolar areas, scars, and asymmetry of the breasts.
Patient satisfaction with the results is often not as great as with other procedures. Satisfaction often depends on how well the patient is prepared to accept the resulting scars.
Reduction mammoplasty is similar to mastopexy, since nearly all hypertrophic breasts are ptotic and must be lifted during correction. Enlargement can occur during puberty or later in life. Massive breasts can become a significant disability to the patient.
Although various techniques have been developed for breast reduction, nearly all require a pedicle to carry the nipple areola to its new position and a circumareolar incision as well as a vertical or inverted T incision beneath the areola. In gigantomastia, the nipple-areola is often removed as a free full-thickness graft and positioned appropriately. Most tissue is removed from the center and lower poles of the breast.
Vertical reduction mammoplasty has aroused considerable recent interest because of the decrease in amount of scarring. It can be accomplished through an incision made circumferentially around the areola and then a vertical incision that extends to and sometimes slightly below the inframammary fold. Resection of the breast tissue is done from below as well as from the lateral aspect of the breast. Considerable wrinkling of the skin occurs in an effort to avoid “T-ing off” the incision at the inframammary fold, but pleating of the skin usually resolves over a period of weeks. General anesthesia is nearly always required because dissection is considerable, but blood loss can be minimized by the use of epinephrine as a vasoconstriction agent. Transfusions are rarely indicated, and postoperative drains are often not used. The procedure can be done on an outpatient basis.
Although problems with nipple-areola loss, bleeding, infection, asymmetry of breasts, and scarring may occur; these women are generally among the most satisfied and appreciative of patients.
ABDOMINOPLASTY & BODY CONTOURING PROCEDURES
Other procedures usually classified as aesthetic are abdominoplasty and various body contouring procedures that serve to remove excess tissue from the lower trunk, thighs, and upper arms. Patients with sagging tissue due to aging, pregnancies, multiple abdominal operations, or significant or massive weight loss are usually good candidates for body contouring procedures. With the increased popularity of bariatric surgery, more people are seeking surgery to remove and correct large amounts of excess and redundant skin and soft tissue of the trunk and extremities. These types of procedures are not indicated as a treatment for obesity. This involves a complete regimen of diet, exercise, and lifestyle modifications.
Abdominoplasty usually involves removal of a large ellipse of skin and fat down to the wall of the lower abdomen. Dissection is carried out in the same plane up to the costal margin. The naval is circumscribed and left in place. After the upper abdominal flap is stretched to the suprapubic incision, excess skin and fat are excised. The fascia of the abdominal wall midline can be plicated and thus tightened. The umbilicus is exteriorized through an incision in the flap at the proper level, and the wound is closed over drains with a long incision generally in an oblique line or W shape just above the os pubis and out to the area below the anterior iliac crests (so-called bikini line). When the extent of excess abdominal tissue is severe, better results can be obtained with what is called a circumferential abdominoplasty. The incision is carried around the patient and this requires changing the position of the patient at least on one occasion. Proper markings preoperatively are essential in order to obtain a satisfactory and symmetrical result.
Spinal anesthesia may be used in some cases. Hospitalization is routinely required for up to a few days. Blood transfusions are rarely necessary. Proper deep vein thrombosis prophylaxis is important in these and other extensive procedures.
Complications involve blood or serum collections beneath the flap, infection, tissue loss, and wide scars. Results are generally quite dramatic with excellent patient satisfaction in properly selected cases.
Various surgical procedures have been devised to remove excess skin and fat from the upper arms, buttocks, and thighs. These procedures commonly result in extensive incisions that can produce significant scarring, and there may be difficulty in achieving a smooth transition between the end point of the contour alteration and normal tissue. Careful planning and counseling of the patient is imperative in order to obtain a satisfactory result. The use of a suction-assisted lipectomy with appropriate cannulas to remove localized excess fat deposits has become widespread. It is clear, however, that patient selection and judicious use of liposuction are necessary to avoid complications, including hypovolemia due to blood loss, hematoma formation, skin sloughs, excess laxity of the skin and soft tissues and waviness and depressions in the operative site. Used with discretion, liposuction can offer definition to areas of the abdomen, flanks, thighs, and buttocks.
Suction-assisted lipectomy, or liposuction, has now become the most common cosmetic surgical procedure performed in the United States. As presently practiced, it consists of infiltration of a “wetting” or “tumescent” solution to provide vasoconstriction and anesthesia to the operative sites. A common mixture consists in a solution of Ringer lactate with the addition of 1 mg of epinephrine per 1000 mL of Ringer and 250 mg of plain lidocaine—the former to provide vasoconstriction and the lidocaine to provide a certain amount of anesthesia and thus reduce the depth of general anesthesia. Some surgeons perform the entire operation under local anesthesia, necessitating the use of larger amounts of lidocaine.
Once the solution has been infiltrated sufficiently to produce the proposed effects, a small cannula is introduced through a small incision and suction is applied either with a syringe or with a suction machine. The fat layer that has been enlarged by the injection of tumescent solution dislodges easily and disrupts much faster than the blood vessels and the nerves.
Suction-assisted lipectomy is effective in removing abnormal bulges of localized fat throughout the body, particularly in the trochanters or the abdomen and flanks, but it is not considered a weight reduction technique.
The procedure is safe when done by well-trained surgeons respecting sterility and technique and in adequately equipped operating rooms. Safety in the use of up to 35 mg of lidocaine per kilogram has been established by clinical studies. Although fatalities have been reported with suction-assisted lipectomy—which is distressing in an entirely elective procedure—they are due to pulmonary embolization, perforation of the intestines, or severe infections of the abdominal wall. Fortunately, fatalities have markedly decreased since the American Society of Plastic and Reconstructive Surgeons established safety guidelines. High-volume liposuction (ie, over 5000 cc of aspirate) should be done in a hospital or accredited ambulatory facility and that combined procedures should be carefully monitored.
Complications of suction-assisted lipectomy include irregularities of contour, dimpling, and, rarely, local infection at the entrance points.
Ultrasonic liposuction, external and internal, has also been advocated. External ultrasonic liposuction has the effect of a massage to disperse the infiltrated tumescent solution. Internal ultrasonic liposuction, on the other hand, emulsifies the fat with ultrasonic energy, which produces heat, so that this emulsified fat needs to be suctioned with standard suctioning equipment. The problems with ultrasonic liposuction include seroma formation, the need for larger portals of entrance, the possibility of burns of the skin or perforations of the skin (end hits) if the cannula is misdirected.
TM, El Tal
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With the continued popularity of lipectomy and the desire for contouring of other body regions, the use of fat grafting has continued to gain popularity. In essence, fat is removed from one part of a patient, prepared via several different techniques, and then placed where further soft tissue enhancement is required. It can be used in the face, the breast, and soft tissue defects in almost all areas of the body. With the discovery of adipose derived stem cells, this technique will continue to gain popularity.
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A: Clinical analyses of clustered microcalcifications after autologous fat injection for breast augmentation. Plast Reconstr Surg 2012;129(1):168e.
TELANGIECTASIAS (SPIDER VEINS)
When there is no trace of primary or secondary varicosities, most telangiectasias, or spider veins, are viewed as a cosmetic problem. However, one should be aware that in some cases spider veins may be an indication of deep venous valvular insufficiency. Factors that may play a role in the formation of spider veins include venostasis with decreased flow rate due to atony of the venous wall, chronic venous inflammation, trauma to the site, hormonal influences, or venous compression at the saphenofemoral valve.
Treatment of spider veins is with sclerosing agents, which may include hypertonic saline, sodium tetradecyl sulfate, and polidocanol (Asclera) injections. These agents are injected directly into the spider veins with the objective of creating intimal damage that will result in fibrosis and obliteration of the lumen. The technique is simple and effective, but when the sclerosing agent extravasates into the soft tissue, it might produce superficial skin necrosis.