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
Is Discussed in Chapter 44.
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
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
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.
Scheinfeld N, Lehman DS: An evidence-based
review of medical and surgical treatments of genital warts. Dermatol
Online J 2006;12:5.
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
Surgical excision is nearly always the treatment of choice. Pigmented
nevi should never be treated without obtaining tissue for histologic
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
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
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
Gur E, Zuker R: Complex facial nevi: a surgical
algorithm. Plast Reconstr Surg 2000;106:25.
& 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,
The terminology of these vascular anomalies was previously based
on anatomical, clinical, histologic, or descriptive features, contributing
to much confusion in identifying the hemangioma. For example, the
histologic term capillary hemangioma has been used
for both the common involuting hemangioma of childhood that disappears
by age 7 and the port wine stain that persists into adulthood. The
term cavernous is used to designate several types
of hemangiomas that behave quite differently. Some hemangiomas are
true neoplasms arising from endothelial cells and other vascular
elements (such as involuting hemangiomas of childhood, endotheliomas,
and pericytomas). Others are not true neoplasms but rather malformations of
normal vascular structures (eg, port wine stains, cavernous hemangiomas, and
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 RICH, 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
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
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 in most cases is
complete by 5–7 years of age.
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.
The histologic findings in involuting hemangiomas are quite different
from those seen in other types of hemangiomas. There is a constant
correlation between the histologic picture and the clinical course.
During the growth phase, the lesion is composed of solid fields
of closely packed round or oval endothelial cells. As would be expected
during the growth phase, cellular division with mitotic figures
is seen, so that the lesion is sometimes called a hemangioendothelioma
by the pathologist. This term should not be used, however, because
it is commonly used to denote the highly malignant angiosarcoma
that is seen in adults.
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.
Partial resection of a portion of a hemangioma of the brow or
eyelid is indicated when the lesion is large enough to prevent light
from entering the eye—a condition that will lead to blindness
or amblyopia. The same type of treatment may be necessary for lesions
of the mucosal surfaces of the lips when they project into the mouth
and are traumatized by the teeth. In these cases, surgery should
be very conservative—only enough of the lesion should be
resected to alleviate the problem, and the remaining portions should
be allowed to involute spontaneously.
In approximately 8% of cases, ulceration will occur.
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.
After involution of large lesions, superficial scarring may be
present or the involved skin may be thin, wrinkled, or redundant.
These conditions may require conservative plastic surgery procedures.
The application of local agents such as dry ice to the surface
of these lesions has been popular. This type of treatment has no
effect on the deep portions of the hemangioma. It will destroy superficial
lesions but results in severe scarring. Injections of sclerosing
agents have minimal effect. There is no place for radiation therapy
in the treatment of these benign lesions. Corticosteroids given systemically
or intralesionally have been used with varying success and should
be considered if conservative measures are inadequate. Anecdotal
evidence exists in favor of compression to speed up the involution
process and give a better final result. Although surface laser therapy
has little or no effect on these large hemangiomas, some have proposed
the insertion of a laser probe deep into the lesion so that the
heat generated by the laser produces contracture of the hemangioma.
This may slow down the accelerated growth and trigger involution.
In cases of life-threatening hemangiomas associated with Kasabach-Merritt
syndrome or hemangiomas of the head and neck area that are obstructing
the airway or vision, systemic interferon alfa has been shown to be
extremely effective especially in those cases that are resistant
Achauer BM et al: Intralesional photocoagulation of periorbital
hemangiomas. Plast Reconstr Surg 1999;103:11.
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: rapidly involuting (RICH)
and noninvoluting (NICH) congenital hemangiomas. 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.
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 41–9).
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
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
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 longstanding 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
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.
Arteriovenous malformations are high-flow lesions having a direct
connection between an artery and a vein, bypassing the capillary
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.
Arneja JS, Gosain AK: Vascular malformations.
Plast Recon Surgery 2008;121:195e.
Chang MW: Updated classification of hemangiomas and other vascular
anomalies. Lymphat Res Biol 2003;1:259.
Enjolras O, Mulliken JB: Vascular tumors and vascular malformations
(new issues). Adv Dermatol 1997;13:375.
Mulliken JB, Fishman SJ, Burrows PE: Vascular anomalies. Curr Probl
Mulliken JB, Glowacki J: Hemangiomas and vascular malformations
in infants and children: a classification based on endothelial characteristics.
Plast Reconstr Surg 1982;69:412.
North PE et al: GLUT1: A newly discovered immunohistochemical
marker for juvenile hemangiomas. Human Pathol 2000;31:11.
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
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
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
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.
Intraepidermal carcinoma includes Bowen disease and erythroplasia
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
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
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
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.
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.
When used as treatment for superficial basal cell carcinoma,
curettage and electrodesiccation is a simple, quick, and inexpensive
procedure that will cure nearly all superficial lesions. However, this
method of treatment should not be used in the deeper infiltrative
and morphea type lesions. These lesions should be treated by surgical
excision, x-ray therapy, or chemosurgery.
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
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 in 1941
a new technique 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
Mohs FE: Mohs micrographic surgery. A historical
perspective. Dermatol Clin 1989;7:609.
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.
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
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
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. The advantages and disadvantages of
each type of therapy are discussed earlier. 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.
Because the overall incidence of lymph node metastasis is relatively
low, most authorities agree that node resection is not indicated
in the absence of palpable regional lymph nodes except in the case of
very aggressive carcinomas of the genitalia and anal regions.
Alam M, Ratner D: Cutaneous squamous-cell carcinoma.
N Engl J Med 2001;344:975.
Arbuckle HA, Morelli JG: Pigmentary disorders: update on neurofibromatosis-1 and
tuberous sclerosis. Curr Opin Pediatr 2000;12:354.
Kanzler MH, Mraz-Gernhard S: Treatment of primary cutaneous
melanoma. JAMA 2001;285:1819.
Lentsch EJ, Myers JN: Melanoma of the head and neck: current
concepts in diagnosis and management. Laryngoscope 2001;111:1209.
Stadelmann WK et al: Cutaneous melanoma of the head and neck:
advances in evaluation and treatment. Plast Reconstr Surg 2000;105:2105.
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
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
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 can a decision 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 mid face 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
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.
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.
Antonyshyn O, Gruss JS: Complex orbital trauma:
the role of rigid fixation and primary bone grafting. Plast Reconstr
Surg 1988; 7:61.
Krsarai L et al: A biomechanical analysis of the orbital zygomatic
complex in human cadavers: examination of load sharing and failure
patterns after fixation with titanium and bioresorbable systems. J
Craniofac Surg 1999;10:400.
Thaller SR, Kawamoto HK: A histologic evaluation of fracture
repair in the midface. Plast Reconstr Surg 1990;85:196.
Thaller SR, Mabourakh S: Pediatric mandibular fractures. Ann
Plast Surg 1991;26:511.
Yaremchuk MJ: Vascularized bone grafts for maxillofacial reconstruction.
Clin Plast Surg 1989;16:29.
& 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 10th 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 mid face. 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
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.
Estes JM et al: Endoscopic creation and repair
of fetal cleft lip. Plast Reconstr Surg 1992;90:743.
Lorenz HP, Longaker MT:
In utero surgery for cleft
lip/palate: minimizing the “ripple effect” of
scarring. J Craniofac Surg 2003;14:504.
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 41–10).
Tessier classification of craniofacial clefts. The numbering
system goes from 0 to 14, and the skeletal defects mimic the soft
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
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
2 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.
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.
Cohen SR: Craniofacial distraction with a modular
internal distraction system: evolution of design and surgical techniques. Plast
Reconstr Surg 1999;103:1592.
McCarthy JG: The timing of surgical intervention in craniofacial
anomalies. Clin Plast Surg 1990;17:161.
Nocini PF et al: Vertical distraction of a free vascularized
fibula flap in a reconstructed hemimandible: case report. J Craniomaxillofac
Romo T 3rd, Presti PM, Yalamanchili HR: Medpor alternative
for microtia repair. Facial Plast Surg Clin North Am 2006;14:129.
Head & Neck
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. Tissue attached to an adequate blood supply must be used
to ensure early and watertight healing in the mouth and oropharynx,
in areas of radiation injury, and over metal or other alloplastic
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.
Lutz BS, Wei FC: Microsurgical workhorse
flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421.
Pearl RM et al: An approach to mandibular reconstruction. Ann
Plast Surg 1988;21:401.
Santamaria E et al: Sensation recovery on innervated radial
forearm flap for hemiglossectomy reconstruction by using different
recipient nerves. Plast Reconstr Surg 1999;103:450.
Yamamoto Y et al: Superiority of end-to-side anastomosis with
the internal jugular vein: the experience of 80 cases in head and
neck microsurgical reconstruction. Br J Plastic Surg 1999;52:88.
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 is also a popular method of breast
reconstruction. A partially filled silicone envelope with a separate
valve is inserted under the chest skin and muscle, and at intervals over
a period of 6 weeks to 3 months the bag 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.
The disadvantages of this method include the rare occurrence of
the hemispheric expansion of the skin, which may result in a hard,
rounded breast mound; the necessity for a second operation; and problems
with infection, deflation, exposure of the prosthesis, and occasional skin
necrosis when expansion is too rapid.
The transverse rectus abdominis myocutaneous (TRAM) flap based
on the superior epigastric vessel has been successfully used to
provide adequate tissue so that an implant is not required in reconstructing
the breast. This is the most versatile method of reconstruction in
that one can usually obtain as much tissue as necessary to match
the opposite breast and to contour it and position it to simulate
the shape as well as the size of the opposite breast. 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. Both
techniques that spare the rectus abdominis and its innervation require
more operative time and careful dissection. However, to some degree
they seem to have a similar decrease in donor site morbidity with regard
to avoiding an abdominal bulge and maintaining more muscle function.
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.
Bostwick J III: Breast reconstruction after mastectomy.
Semin Surg Oncol 1988;4:274.
Hartrampf CR Jr: The transverse abdominal island flap for breast reconstruction:
a 7-year experience. Clin Plast Surg 1988;15:703.
Lejour M, Jabri M, Deraemaecker R: Analysis of long-term results
of 326 breast reconstructions. Clin Plast Surg 1988;15:689.
Nahabedian MY et al: Breast reconstruction with the DIEP flap
or the muscle-sparing (MS-2) free TRAM flap: is there a difference?
Plast Reconstr Surg 2005;115:436.
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 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
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
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
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 masklike 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 mid face
has given more natural and lasting results and provides also a 3D
type of restoration of the soft tissues, giving a more youthful
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
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.
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
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 midface
lift, and this procedure is applicable to younger patients where
there is no excess skin in the face or neck and where scars will
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
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
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
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.
Rohrich RJ, Reece EM: Breast augmentation today:
saline versus silicone—what are the facts? Plast Recon
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.
& 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
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
Complications of suction-assisted lipectomy include irregularities
of contour, dimpling, and, rarely, local infection at the entrance
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.
Cardoso de Castro C: The changing role of platysma in face lifting.
Plast Reconstr Surg 2000;105:764.
Chajchir A: Fat injection: long-term follow-up. Aesthetic Plast
Matarasso A, Hutchinson OH: Evaluating rejuvenation of the forehead
and brow: an algorithm for selecting the appropriate technique.
Plast Reconstr Surg 2000;106:687.
Pitanguy I: Facial cosmetic surgery: a 30-year perspective.
Plast Reconstr Surg 2000;105:1517.
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 hydroxypolyethoxydodecan
(Sclerovein). 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 necroses.