Facial Reconstruction after Fracture
As technologic advances raise the level of energy involved in modern systems of transportation, recreation, and weaponry, so follow increases in the degree of maxillofacial destruction related to misadventures with this technology. The first phase of care for the patient with maxillofacial trauma is activation of the advanced trauma life support protocol. Concomitant injuries beyond the face are the rule rather than the exception. The most common life-threatening considerations in the facial trauma patient are airway maintenance, control of bleeding, identification and treatment of aspiration, and identification of other injuries. Once the patient’s condition has been stabilized and life-threatening injuries treated, attention is directed to diagnosis and management of craniofacial injuries.
Physical examination of the face with attention to lacerations, bony step-offs, instability, tenderness, ecchymosis, facial asymmetry, and deformity guides the examiner to underlying hard tissue injuries. Traditional specialized radiography has largely been replaced by widely available high-resolution CT. Coronal, sagittal, and three-dimensional reconstructions of images further elucidate complex injuries.
Mandibular fractures are common injuries that may lead to permanent disability if not diagnosed and properly treated. The mandibular angle, ramus, coronoid process, and condyle are points of attachment for the muscles of mastication, including the masseter, temporalis, lateral pterygoid, and medial pterygoid muscles (Fig. 45-26). Fractures are frequently multiple, and disturbances in dental occlusion reflect the forces of the many muscles of mastication on the fracture segments. Dental occlusion is perhaps the most important basic relationship to understand about fracture of the midface and mandible. The Angle classification system describes the relationship of the maxillary teeth to the mandibular teeth. Class I is normal occlusion, with the mesial buccal cusp of the first maxillary molar fitting into the intercuspal groove of the mandibular first molar. Class II malocclusion is characterized by anterior (mesial) positioning, and class III malocclusion is posterior (distal) positioning of the maxillary teeth with respect to the mandibular teeth (Fig. 45-27).
Mandibular anatomy. (Reproduced with permission from Thornton J, Hollier L. Facial fractures II: lower third. Selected Readings Plast Surg. 2002;9:1.)
Angle classification. Class I: The mesial buccal cusp of the maxillary first molar fits into the intercuspal groove of the mandibular first molar. Class II: The mesial buccal cusp of the maxillary first molar is mesial to the intercuspal groove of the mandibular first molar. Class III: The mesial buccal cusp of the maxillary first molar is distal to the intercuspal groove of the mandibular first molar. (Reproduced with permission from Thornton J, Hollier L. Facial fractures II: lower third. Selected Readings Plast Surg. 2002;9:1.)
Nonsurgical treatment may be used in situations in which there is minimal displacement, preservation of the pretraumatic occlusive relationship, and normal range of motion. The goals of surgical treatment include restoration of pretraumatic dental occlusion, reduction and stable fixation of the fracture, and repair of soft tissue. Operative repair involves seating of the condyles within the glenoid fossa, achievement of maxillary-mandibular fixation with arch bars or intermaxillary screws to establish proper dental occlusion, and intraoral, extraoral, or combination surgical exposure of fracture lines. The mandibular plating approach follows one of two schools of thought: rigid fixation as espoused by the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) and less rigid but functionally stable fixation (Champy technique). Regardless of the stabilization approach, one of the postoperative objectives is release from maxillary-mandibular fixation and resumption of range of motion as soon as possible to minimize the risk of ankylosis. Other potential complications include infection, nonunion, malunion, malocclusion, facial nerve branch injury, infra-alveolar or mental nerve injury, and dental fractures.
Treatment of all but the simplest orbital injuries should include evaluation by an eye specialist to assess visual acuity and rule out globe injury. Orbital fractures may involve the orbital roof, floor, or lateral or medial walls. The most common orbital fracture is the orbital floor blow-out fracture caused by direct pressure to the globe and sudden increase in intraorbital pressure. Because the medial floor and inferior medial wall are made of the thinnest bone, fractures occur most frequently at these locations. These injuries may be treated expectantly if they are sufficiently small and without complication. However, larger blow-out fractures and those associated with enophthalmos (increased intraorbital volume), entrapment of inferior orbital tissues, or diplopia lasting >2 weeks generally require surgical treatment.28 There are many approaches to the orbital floor, including the transconjunctival, subciliary, and lower blepharoplasty incisions. All provide access to the orbital floor and allow for repair with a multitude of different autogenous and synthetic materials. Late complications include persistent diplopia, enophthalmos, ectropion, and entropion.
Lateral and inferior orbital rim fractures also are not uncommon and are often associated with the zygomaticomaxillary complex fracture pattern, as discussed later.
Special mention should be made of two uncommon complications after orbital fracture. Superior orbital fissure syndrome results from compression of structures contained in the superior orbital fissure in the posterior orbit. These include cranial nerves III, IV, and VI, and the first sensory division of cranial nerve V. Compression of these structures leads to symptoms of eyelid ptosis, globe proptosis, paralysis of the extraocular muscles, and anesthesia in the cranial nerve V1 distribution. If the optic nerve (cranial nerve II) is also involved, symptoms include blindness and the syndrome is dubbed orbital apex syndrome. Both of these syndromes are medical emergencies, and steroid therapy and surgical decompression are considered.
Zygoma and Zygomaticomaxillary Complex Fractures
The zygoma forms the lateral and inferior borders of the orbit. It articulates with the sphenoid bone in the lateral orbit, the maxilla medially and inferiorly, the frontal bone superiorly, and the temporal bone laterally (Fig. 45-28). Zygoma fractures may involve the arch alone or many of its bony relationships. Isolated arch fractures manifest as a flattened, wide face with associated edema and ecchymosis. Nondisplaced fractures may be treated nonsurgically, whereas displaced and comminuted arch fractures may be reduced and stabilized indirectly (Gilles approach) or, for more complicated fractures, directly through a coronal incision.
Facial bone anatomy. (Reproduced with permission from Hollier and Thornton.28)
The zygomaticomaxillary complex (ZMC) fracture involves disruption of the zygomatic arch, the inferior orbital rim buttress, the zygomaticomaxillary buttress, the lateral orbital wall, and the zygomaticofrontal buttress. The fracture segment tends to rotate laterally and inferiorly, creating an expanded orbital volume, limited mandibular excursion, an inferior cant to the palpebral fissure, and a flattened malar eminence. ZMC fractures are almost always accompanied by numbness in the infraorbital nerve distribution and subconjunctival hematoma. Displaced fractures are treated by exposure through multiple incisions to gain access to all of the buttresses requiring fixation. These include the upper eyelid incision (zygomaticofrontal buttress and lateral orbital wall), the subtarsal or transconjunctival incision (orbital floor and infraorbital rim), and the maxillary gingivobuccal sulcus incision (zygomaticomaxillary buttress). Again, significantly complex zygomatic fractures require wide exposure through a coronal approach.5
Naso-orbital-ethmoid (NOE) fractures are often part of a constellation of panfacial fractures and intracranial injuries. Anatomically, the fracture pattern involves the medial orbits, nasal bones, nasal processes of the frontal bone, and frontal processes of the maxilla. These injuries result in severe functional deficit and cosmetic deformity from collapse of the nose, ethmoids, and medial orbits; displacement of medial canthal ligament fixation; and nasolacrimal apparatus disruption. Telecanthus is produced by splaying apart of the nasomaxillary buttresses to which the medial canthal ligaments are attached. Treatment typically involves plating or wiring all bone fragments meticulously, potentially with primary bone grafting, to restore their normal configuration. Key to the successful repair of an NOE fracture is the careful re-establishment of the nasomaxillary buttress and restoration of the pretrauma fixation points of the medial canthal ligaments. If comminution is severe, this may be achievable using transnasal wiring of the ligaments.
The region of the frontal sinus is a relatively weak structural point in the upper face. For this reason, it is a common location for fracture in facial trauma. The paired sinuses each have an anterior bony table that determines the contour of the forehead and a posterior table that separates the sinus from the dura. Each sinus drains through the medial floor into its frontonasal duct, which empties into the middle meatus within the nose. Treatment of a frontal sinus fracture depends on the fracture characteristics (Fig. 45-29).
Algorithm for the treatment of frontal sinus fracture. CSF = cerebrospinal fluid; CT = computed tomography; NF = nasofrontal; ORIF = open reduction, internal fixation.
The nose is the most common facial fracture site due to its prominent location, and such fracture can involve the cartilaginous nasal septum, the nasal bones, or both. It is important to perform an intranasal examination to determine whether a septal hematoma is present. If present, a septal hematoma must be incised, drained, and packed to prevent pressure necrosis of the nasal septum and long-term midvault collapse. Closed reduction of nasal fractures may be performed under local or general anesthesia. Unfortunately, many, if not most, show some deformity upon final healing, requiring rhinoplasty if airway obstruction is present or if improved appearance is desired.
Fractures of multiple bones in various locations fall into the category of panfacial fracture. These may involve frontal and maxillary sinus fractures, NOE fractures, orbital and ZMC fractures, palatal fractures, and complex mandible fractures. The difficulty in the repair of these injuries lies not in the technical aspects of fixation but in the reestablishment of normal relationships between facial features in the absence of all pretraumatic reference points. Without proper correction of bony fragment relationships, facial width is exaggerated and facial projection is lost. The key point in approaching the patient with a panfacial fracture is first to reduce and repair the zygomatic arches and frontal bar to establish the frame and width of the face. The nasomaxillary and zygomaticomaxillary buttresses may then be repaired within this correct frame. Next, the maxilla may be reduced to this framework, followed by palatal fixation if needed. Finally, now that the midface relationships have been corrected, maxillary-mandibular fixation can be applied with the mandible in correct occlusion followed by plating of any mandibular fractures.29
Acquired defects of the auricle have many causes, and many different choices for reconstruction are available. Reconstructive approach often is determined by the size and location of the defect. Small helical lesions may be simply excised as a wedge and closed primarily. Larger defects of the upper and middle thirds of the ear may use antihelical and conchal cartilage reduction patterns to reduce the circumference of the helix to allow primary closure. When helical defects are too large for this solution, local flaps may be used to close or re-create the missing tissue. Postauricular flaps created in staged procedures may be manipulated to create a skin tube mimicking the furled helix and bridging the gap of a defect. Alternatively, use of an Antia-Buch chondrocutaneous advancement flap combined with cartilaginous reduction allows for closure of defects30 (Fig. 45-30). Even larger defects of the upper and middle thirds of the ear may be reconstructed with large local skin flaps combined with contralateral cartilage grafts or contralateral composite grafts. Although ear lobe defects are relatively simple to close primarily, lower third auricular defects that involve more than just the lobe are complex and require cartilaginous support, often combined with local skin flaps.
Modified Antia-Buch ear reconstruction. A. Superior helix lesion. B. Excision pattern and reconstruction markings. C. Defect, flap elevation, and cartilage reduction. D. V-Y advancement of the flap. E. Flap insetting. F. Appearance at 1 month after surgery. (Photographs reproduced with permission from M. Gimbel.)
Reconstruction of the nose requires appreciation of the nine aesthetic subunits that are defined by normal anatomic contours and lighting patterns (Fig. 45-31). In general, if a defect involves ≥50% of a subunit, the remainder of the subunit should be excised and included in the reconstruction. The nose can be thought of as being composed of three layers: skin cover, structural support, and mucosal lining. When a defect or anticipated defect is evaluated, it is useful to consider what layers of tissue will be missing so that a reconstruction can be devised that replaces each layer. Healing by secondary intention is successfully used in concavities such as the alar groove. Split- or full-thickness skin grafts may be used for superficial defects of the nasal dorsum or sidewall. Composite grafts may be used for the nasal tip or alar rim (see Fig. 45-3). Local random pattern flaps are useful in closing small defects of the dorsum and tip and may be combined with cartilage grafts if structural support is needed. Axial pattern flaps are commonly used for larger defects. These flaps have the advantage of being able to cover and revascularize underlying cartilage grafts and enjoy a close color match to surrounding skin. Workhorse flaps used in nasal reconstruction include the nasolabial flap and the paramedian forehead flap (Fig. 45-32). Even larger defects may require scalping flaps or free radial forearm flaps. Split calvarial cantilever bone grafts may provide the nasal dorsum support. Lining is generally achieved with scar tissue turnover flaps, mucoperichondrial flaps from within the nasal vestibule, or skin grafting of the underside of transposed flaps.
Nasal aesthetic subunits. (Photograph reproduced with permission from M. Gimbel.)
Nasal reconstruction with axial pattern flaps. Top row: Nasolabial flap reconstruction of an alar defect. Bottom row: Paramedian forehead flap reconstruction of the nasal lobule. (Photographs reproduced with permission from M. Gimbel.)
The lips are important for articulate speech, eating, maintenance of oral competence, facial expression, and aesthetic harmony of the lower face. Three layers of tissue form the upper and lower lips: skin, muscle, and mucosa. Blood supply is through the facial artery and its branches to the lip, the superior and inferior labial arteries. Lip defects can arise from trauma, burns, neoplasms, congenital lesions, clefts, or infection. As with almost all types of reconstruction, choice of technique is heavily dependent on defect size, location, and deficient structures. The goals of lip reconstruction are restoration of the competent oral sphincter with vermilion apposition, preservation of sensation, and avoidance of microstomia, all while preserving a near-normal static and dynamic appearance. In the upper and lower lip, vermilion-only defects can be corrected with advancement of the labial mucosa, often called a lip shave. In defects of less than one-third the horizontal length, enough redundancy is present to allow primary closure. More complex decisions must be made for defects that are between one-third and two-thirds of the total lip length.
The two categories of lip flap technique are transoral cross-lip flaps and circumoral advancements flaps. Cross-lip flaps include the Abbé flap and the Estlander flap. The Abbé flap was originally designed to reconstruct central upper lip (tubercle) defects with lower lip full-thickness tissue vascularized by one of the labial arteries (Fig. 45-33). The technique requires a second-stage procedure for division of the pedicle. The Estlander flap is similar in principle but is based laterally at the oral commissure and is used to reconstruct lateral upper or lower lip lesions. Both the Estlander and Abbé flaps are denervated, but sensation and perhaps even motor function return over months.31 The Karapandzic technique is an advancement-rotation flap technique designed for central lower lip defects. Although good function, sensation, and mobility are preserved, a side effect is reduction in the size of the oral aperture. The Webster-Bernard technique uses cheek tissue advancement flaps to replace defects with full-thickness or partial-thickness cheek incisions extended laterally from the commissure (Fig. 45-34). When performed bilaterally, both the Karapandzic and the Webster-Bernard methods can be used to reconstruct a complete upper or lower lip.
Abbé flap upper lip reconstruction. A. Defect and flap design. B. Rotation of the flap and primary closure of the donor site. C. Division of the pedicle (after 2 to 3 weeks) and final insetting.
Webster-Bernard lip reconstruction technique. (Reproduced with permission from Closmann JJ, Pogrel A, Schmidt BL. Reconstruction of perioral defects following resection for oral squamous cell carcinoma. J Oral Maxillofac Surg. 2006;64:367. Copyright Elsevier.)
In addition, microvascular free tissue transfer reconstruction may be necessary in cases where there is no remaining lip. The radial forearm free flap is the most commonly used for this purpose, usually transferred with the palmaris longus tendon for lip support.
The eyelids protect the eye from exposure and are another crucial aesthetic structure of the face. They consist of an anterior lamella (skin and orbicularis oculi muscle) and a posterior lamella (tarsus and conjunctiva). The eyelid blood supply is robust, and ischemia is rarely a concern in reconstruction.
Defects comprising <25% of the upper eyelid can generally be closed primarily in pentagonal approximating fashion (Fig. 45-35). For defects involving 25% to 50% of the upper eyelid, lateral canthotomy (release of the lateral canthal tendon) and cantholysis (release of the superior limb of the lateral palpebral tendon) can be performed to allow advancement and are often combined with use of a lateral semicircular flap (Fig. 45-36). Defects larger than 50% of the upper eyelid may be reconstructed with a Cutler-Beard full-thickness advancement flap or a modified Hughes tarsoconjunctival advancement flap (Fig. 45-37).
Upper eyelid defect of <25%. Primary closure. (Reproduced with permission from Pham RT. Reconstruction of the upper eyelid. Otolaryngol Clin North Am. 2005;38:1023. Copyright Elsevier.)
Upper eyelid defect of 25% to 50%. A. Lateral canthotomy. B. Semicircular flap. (Reproduced with permission from Pham RT. Reconstruction of the upper eyelid. Otolaryngol Clin North Am. 2005;38:1023. Copyright Elsevier.)
Upper eyelid defect of >50%. A and B. Cutler-Beard full-thickness lower eyelid advancement flap. C and D. Hughes lower eyelid tarsoconjunctival advancement flap. (Reproduced with permission from Pham RT. Reconstruction of the upper eyelid. Otolaryngol Clin North Am. 2005;38:1023. Copyright Elsevier.)
Lower eyelid reconstruction considerations parallel those for the upper eyelid. In addition, special attention must be given to the prevention of scleral visibility and ectropion, which can arise from excessive vertical tension due to either technique or scarring. Similar reconstructive methods may be used, including direct closure, semicircular flaps and canthal release, and advancement flaps. Grafts may also be used if the defect is partial thickness. Full-thickness contralateral upper eyelid skin grafts are suitable for replacing the anterior lamella. The posterior lamella requires sturdy, nonkeratinized graft tissue, such as cartilage (tarsal, ear, or nasal septal) or hard palate mucosal grafts, to allow globe apposition.32
In the normal eyelid, the orbicularis oculi muscle, Müller’s muscle, and levator palpebrae muscle act in concert to open and close the palpebral aperture and to maintain the level of the upper eyelid with respect to the pupil. Eyelid ptosis is created by derangement of this cooperative action. Ptosis may be congenital or acquired. Congenital ptosis is caused by lid anomalies, ophthalmoplegia, and synkinesis, whereas acquired ptosis can be neurogenic, myogenic, or traumatic in nature. Horner’s syndrome is a form of neurogenic ptosis caused by interrupted sympathetic innervation that leads to ptosis, miosis, and anhydrosis. A thorough evaluation of the ptotic patient includes a general eye and visual acuity examination, attention to signs of exposure or irritation, measurement of marginal-reflex distance, observation of the height of the supratarsal fold, and assessment of levator function. Severity of ptosis and degree of levator dysfunction are critical in deciding the appropriate corrective procedure (Table 45-11). Mild ptosis may be addressed with the Fasanella-Servat procedure, which involves excision of the superior tarsal edge, conjunctiva, and levator aponeurosis, and mullerectomy. Other corrections of mild ptosis usually involve variations on this procedure. Moderate ptosis with fair to good levator function may be treated with some form of a levator aponeurosis shortening procedure. Severe ptosis with poor levator function requires use of an alternate eyelid motor. The frontalis muscle fascial sling technique, which uses strips of fascial grafts sutured to the frontalis muscle, is one such solution.
Table 45-11Eyelid ptosis classification ||Download (.pdf) Table 45-11 Eyelid ptosis classification
|Classification of ptosis severity || |
| Mild ||1–2 mm |
| Moderate ||3 mm |
| Severe ||4+ mm |
|Classification of levator function || |
| Excellent ||12–15 mm |
| Good ||8–12 mm |
| Fair ||5–7 mm |
| Poor ||2–4 mm |
Skull and Scalp Reconstruction
The scalp is formed of five layers: Skin, subCutaneous tissue, galea Aponeurotica, Loose areolar tissue, and Pericranium (SCALP). The scalp is well vascularized bilaterally by branches of the external carotid artery, including the superficial temporal arteries, the occipital arteries, and the posterior auricular arteries. In addition, the bilateral supraorbital and supratrochlear arteries contribute to the forehead and anterior scalp blood supply. These vessels run in the subcutaneous tissue layer, just superficial to the galea. Because of this rich blood supply, scalp lacerations can lead to dramatic blood loss, an event that usually can be curtailed by a simple running/locking suture closure.
Partial-thickness scalp loss due to trauma usually occurs at the level of the loose areolar tissue plane and is treated initially with débridement of devitalized tissue. If a partial-thickness defect is small enough, primary closure or skin graft can be used. Although the cosmetic result is often less than desirable, all layers of the scalp will accept a skin graft, including the calvaria if it is burred down to its diploë. Because the scalp is relatively inelastic, scoring of the galeal layer often facilitates closure of full-thickness defects, but care must be taken to avoid lacerating the blood vessels just superficial to the galea. Larger areas of loss (4–8 cm) may be covered with large scalp flaps, as classically described by Orticochea.33 Grafting of defects or donor sites leaves a visible area of alopecia. Tissue expansion has been very successful in replacing scarred or grafted regions with hair-bearing skin. Defects larger than 8 to 10 cm are best treated with microsurgical free tissue transfer. Total or subtotal scalp avulsions are rare injuries that usually occur when a person’s long hair becomes caught in rotating machinery. These potentially devastating injuries are ideally treated by scalp replantation, because the avulsed segment usually has preserved vessels (Fig. 45-38).
Twenty-five-year-old woman with 70% scalp avulsion after a pedestrian-automobile accident. Top row: Defect and specimen intraoperatively. Bottom row: Appearance 9 weeks after microsurgical scalp replantation. (Photographs reproduced with permission from M. Gimbel.)
Autogenous bone remains the material of choice for reconstruction of skull defects. Its advantages include resistance to infection and ability to heal with strength. All autogenous bone sources have the disadvantage of donor site morbidity. Bone grafts can be harvested from a normal area of the calvaria, of which the outer table may be used as a graft for defects of limited size. Care must be taken during harvest to avoid compromise of the inner table. Rib bone may also be used, either as a split-rib graft or as a microsurgical free osseous flap. Unfortunately, use of ribs to reconstruct the skull may give an unappealing “washboard” appearance to the scalp. Another disadvantage of bone grafts, although not flaps, is graft resorption over time.
Alternative materials to autogenous bone exist for calvarial reconstruction, including methyl methacrylate, titanium, and hydroxyapatite (with or without bone morphogenic protein). Although they have the advantage of no donor site, these plastics and metals are associated with a higher risk of infection necessitating removal. Various formulations of calcium phosphate hydroxyapatites are being actively studied as bone replacement materials.
Head and Neck Reconstruction
The head and neck region has a compact arrangement of critical and complex structures encasing the essential routes to the gastrointestinal and respiratory systems. The tissues of the face, mouth, and cavities serve as a primary communication interface with the external environment through facial and verbal expression. Therefore, cancer resections with adequate safety margins can be severely and multiply debilitating. The management of head and neck cancer patients demands an integrated multidisciplinary team approach that includes the skills of ablative and reconstructive surgeons, medical and radiation oncologists, pathologists, nutritionists, and functional and psychological rehabilitation specialists.
The freedom available to the ablative surgeon to completely excise a tumor is limited, at least partly, by the capability of the reconstructive surgeon to restore anatomic continuity and achieve successful wound healing. A neck dissection to remove cervical lymphatics and nodes may be performed for prophylactic or curative intent, for more accurate prognostication by operative staging, and/or for solidification of plans for adjunctive treatments. It is important to be familiar with the tumor-node-metastasis (TNM) classification and staging of head and neck cancers. The N and M parameters are fairly constant for most head and neck cancers, whereas the T parameter varies according to tumor location.
Principles of Reconstruction
The reconstructive surgeon aims to restore lost anatomic components adequately. Residual deficits, seemingly inconsequential, may progress to psychological morbidity, societal malacceptance, and social withdrawal. Uncomplicated and timely wound healing is important to allow adjuvant therapies when indicated and smooth discharge to home and occupation.
Each defect can be addressed by a number of methods, but the technique must be decided for each individual patient. Although a more complex reconstruction might offer improved outcomes, it may bring an increased risk of complications. Some patients may therefore benefit from use of a simpler method with more acceptable anesthetic and operative risk rather than a gold-standard reconstruction. Such an approach may be appropriate, for example, for an elderly patient with an advanced T4 cancer and short life expectancy. Reconstruction is impossible for some functional losses, such as the enucleation of an eye, but replacement by a reasonably aesthetic prosthesis may be achievable.34
Reconstructive Options by Region
Before the 1970s, autogenous tissue reconstructions were largely restricted to local or regional pedicled flaps, including the trapezius, pectoralis, and deltopectoral workhorse flaps. With microvascular free tissue transplantation, defects that were previously deemed nearly impossible to reconstruct can now be addressed in a single operation. Consequently, head and neck cancers that were historically unresectable have become more operable.
The reconstructive choice for floor of mouth, tongue, and other intraoral defects is dictated by the dimension of the defect, the volume of tissue lost, and residual tongue mobility. The tongue and adjacent mucosal surfaces heal exceptionally well, so small defects may be treated by primary closure or even left to heal spontaneously. Smaller defects, less than one-fourth glossectomy, may be treated with a skin graft or perhaps primary closure if tongue mobility is preserved. Larger defects, more than one-third glossectomy, call for reconstruction by free tissue transfer, commonly a free radial forearm or anterolateral thigh flap for smaller- or larger-volume defects, respectively. Total glossectomy defects are a major challenge, and no ideal method exists to restore tongue motor functions. The primary goal is to protect the airway from aspiration. Swallowing and articulation are often suboptimal after total glossectomy reconstructions. Options include bulkier myocutaneous free flaps harvested from the anterolateral thigh, the back (latissimus dorsi), or the abdomen (rectus abdominis), or pedicled regional flaps (e.g., latissimus dorsi).35
The reconstructive choice for other intraoral soft tissue defects should also take into consideration the specific characteristics of the defect, such as its thickness and dimensions, and involvement of the oral commissure, facial skin, and/or neck. Buccal defects, for example, may be adequately treated with a radial forearm free flap or a thin anterolateral thigh flap. Thicker defects may be more appropriately reconstructed with a fasciocutaneous anterolateral thigh free flap. Those that extend through the full thickness of the cheek to involve the external facial skin may be reconstructed with a cutaneous or myocutaneous anterolateral thigh free flap that has been folded to address the internal mucosal, external skin, and intervening soft tissue defects simultaneously.36 When the contour of the neck is expected to be sunken and asymmetric after a neck dissection, it is possible to improve symmetry by insetting part of the flap into the neck. This maneuver also obliterates dead space and helps protect the adjacent major neurovascular structures.
Mandibular defects may arise from the ablation of tumors involving the bone itself or from the need to satisfy clearance margins for adjacent soft tissue tumors. Segmental mandibular defects can be classified as isolated bone defects, compound defects (bone and oral lining or skin), composite defects (bone, oral lining, and skin), or extensive composite defects (bone, oral lining, skin, and soft tissues).37 The primary goals of mandibular reconstruction are to restore bony continuity, masticatory (with accurate dental occlusion) and speech functions, and facial contour, and to maintain tongue mobility. Occasionally, a small segmental mandibular defect may be amenable to reconstruction with a nonvascularized bone graft, but these are poorly suited to the forces of mastication and are prone to resorption and failure amid radiotherapy or infection.
The best option for most segmental mandibular defects is the fibula bone free flap with an adjoined skin island supplied by reliable septocutaneous vessels (occasionally musculocutaneous perforators) from the peroneal artery and vein; this is termed a fibula osteoseptocutaneous free flap.38 Its many desirable characteristics include (a) the ability to withstand multiple osteotomies (as long as the periosteal blood supply is protected) so that the bone can be folded to re-create the contour of any mandibular region, (b) an unmatched supply of sturdy bone length (22–26 cm in the adult) sufficient to reconstruct even angle-to-angle defects, (c) a bicorticocancellous structure that can tolerate the forces of mastication as well as the incorporation of osseointegrated dental implants, (d) acceptable donor site morbidity when the flap is appropriately harvested, and (e) a donor site location that allows a two-team approach for simultaneous tumor ablation and flap harvest.39,40 Reasonable alternatives include vascularized bone flaps from the iliac crest, radius, or ribs. Extensive composite mandibular defects may demand more than one free flap (such as one anterolateral thigh free flap with one fibula osteoseptocutaneous free flap) to reconstruct the entire anatomy in one operation.41 Later, dental rehabilitation can be achieved with conventional dentures if alveolar ridge height and soft tissue quality allow. However, for select patients, osseointegrated dental implants offer a far superior alternative. These can be secured into the neomandible, either at the time of reconstruction (primarily; Fig. 45-39) or more commonly at a later stage (secondarily), and ultimately will support a dental prosthesis that can closely match the native dentition for excellent aesthetic and masticatory outcomes.42
Free double-barreled fibula osteoseptocutaneous flap with primary osseointegrated dental implants used to reconstruct a compound segmental mandibular defect from ameloblastoma resection. A. Left parasymphyseal segmental mandibulectomy with contiguous dentition and oral lining. B. The osteotomized fibula osteoseptocutaneous free flap ready to be double-barreled; note that a segment of bone between the two struts (barrels) has been discarded to allow safe folding of the construct without compression or kinking of the intervening periosteal blood supply. C. Segmental reconstruction of the resected inferior alveolar nerve with a cutaneous nerve graft from the fibula donor site to restore mentolabial sensation; note the extent of the segmental mandibular defect. D. Three osseointegrated dental fixtures have been loaded into the upper barrel of the fibula; abutments are fitted to the fixtures to allow accurate occlusal matching with the corresponding maxillary dentition before finalizing fibula fixation. E. The de-epithelialized portion of the skin paddle was used to cover the reconstruction plate as well as to contour the soft tissue profile of the neomandibular margin. F. The skin paddle has been inset to reconstruct the oral lining; note that the fibula osteoseptocutaneous flap is best raised with a skin paddle even when there is no cutaneous defect so that it can provide a sentinel flap monitor of the underlying bone as well as facilitate wound closure. At this point, the dental fixtures are sealed with cover plates under the flap skin paddle but will later be fitted with final abutments and a dental prosthesis. G. Panorex radiograph: By 5 months postoperatively, the fibula had consolidated with the native mandible. H and I. At 10 months, the patient has an aesthetic neomandibular margin as well as functional and accurate occlusion after finalization with a dental prosthesis. (Photographs reproduced with permission from F. Wei.)
Similar principles are also applicable to other bony defects in the head and neck region, including maxillary and other midfacial defects, although non–load-bearing, facial, bone-only defects may be more amenable to nonvascularized bone grafting such as from the calvarium. The goals of midface reconstruction include the restoration of facial contour and projection, achievement of accurately occlusive maxillary dentition, provision of appropriate infraocular support, and sealed separation of adjacent nasal and oral cavities.
Esophagus and Hypopharynx
The goals of reconstruction for esophageal and hypopharyngeal defects, which may be circumferential or partial, are to maintain luminal patency, restore speech and swallowing, and avoid strictures, fistulas, and gastrointestinal anastomotic leaks. Reconstructive options for partial defects include primary closure, if luminal narrowing is insignificant, and skin (or dermal) grafts for partial-lining defects. A regional muscle flap may be useful for patching small full-thickness defects, but larger defects call for free tissue transfer of a jejunal flap or a tubed fasciocutaneous flap.43 The jejunal flap involves the harvest of a proximal segment based on its mesenteric blood supply and inset into the neck in the isoperistaltic direction. Disadvantages of the jejunal flap include halitosis, slow swallowing transit times, and a “wet” voice. Tubed fasciocutaneous free flap options, including the anterolateral thigh and radial forearm flaps, are also popular; however, they may have a greater risk of stricturing than the free jejunal flap. Nevertheless, proponents of such flaps favor the resultant vocal qualities and faster transit times.
Recipient Vessels in the Head and Neck for Free Flaps
Commonly used recipient arteries for free tissue transfer in the head and neck include the ipsilateral superior thyroid, lingual, facial, superficial temporal, and transverse cervical arteries. End-to-side anastomosis with the carotid artery is associated with potentially lethal carotid blow-out injury. Anastomoses with contralateral vessels are useful when ipsilateral vessels are not available, such as in patients with recurrent cancer who have undergone previous free flap procedures or irradiation.36 Vein grafts can be avoided by using carefully planned flaps that offer longer pedicles (such as the anterolateral thigh of fibula osteoseptocutaneous free flaps) but may occasionally be necessary. For venous drainage, tributaries of the superficial and deep jugular systems are convenient. Finally, protection of the major vessels and nerves of the neck is possible after neck dissection by overlaying residual free flap tissues. This also aids in improving the contour and symmetry of the neck for aesthetic purposes and obliterates any dead space.
Apart from the general complications that may be encountered with any major operation, there are several specific potential complications of head and neck ablative and reconstructive surgery. Specific intraoperative complications include air embolus, pneumothorax, and injuries to important vessels, lymphatics, or cranial nerves. Specific perioperative complications include carotid artery blow-out, flap necrosis, infections, saliva or chyle leakage, airway problems, and acute psychiatric disturbances. Examples of later complications are prolonged pain syndromes, fistulas, scar contractures, and problems associated with radiotherapy such as flap shrinkage (potentially with metalwork exposure) and osteoradionecrosis.
Facial nerve paralysis is a debilitating and emotionally depressing condition that presents many functional and aesthetic problems. Loss of mimetic muscle activity leads to poor articulation and drooling from oral incompetence, exposure keratopathy from dysfunctional lacrimation and paralytic ectropion, and impaired socialization from facial disfigurement and difficulty expressing emotion. Facial nerve dysfunction has a number of possible causes, including oncologic resection, temporal bone or skull base surgery, trauma, congenital conditions (Möbius’ syndrome), and idiopathic origin. The main considerations in treatment are management of forehead and brow symmetry, eyelid closure, oral competence and symmetry, and smile dynamics. The long-term goals include normal static appearance, symmetry with movement, and restoration of voluntary muscular control. Although the best results usually require multistaged, complex surgeries, the elderly patient is better served by a single-stage procedure that provides immediate improvement.
Traumatic injuries to the facial nerve without segmental nerve loss are best treated with primary end-to-end neurorrhaphy of the facial nerve stumps. The success of this repair depends on accurate approximation of nerve ends and achievement of a tension-free epineural repair with fine sutures. In segmental facial nerve loss due to trauma or oncologic resection, interpositional nerve grafts lead to the most successful reconstruction and may approach the results of primary repair. Grafting ideally is performed at the time of the injury rather than in delayed fashion. Donor nerves include the cervical plexus, great auricular nerve, and sural nerve. Timing of reanimation after nerve repair depends on distance of the repair from the motor end plates. Axonal regeneration proceeds at approximately 1 mm/d, whereas motor end plates deteriorate at approximately 1% per week and are gone by 2 to 3 years. In general, facial tone returns approximately 6 months after repair and voluntary motion a few months later.44 Problems associated with facial nerve repair and grafting are weakness, mass movement (synkinesia), and dyskinesia. If the proximal facial nerve stump is available but the distal stumps are not, the cervical plexus can be harvested and proximally anastomosed to the facial nerve stump and distally implanted into the mimetic muscles to allow neurotization and partial restoration of function.
Nerve transfer techniques borrow other local cranial nerves to innervate the distal facial nerve stump if grafting cannot be done. This requires the availability of distal facial nerve or nerve branch stumps. Typically used donor nerves include the ipsilateral hypoglossal nerve, spinal accessory nerve, and cross-face sural nerve graft from a contralateral facial nerve branch (redundant buccal or zygomatic branch). Disadvantages of this technique include those of nerve repair or grafting plus loss of donor nerve function and facial hypertonia. Transfer of the complete hypoglossal nerve creates ipsilateral tongue paralysis and hemitongue atrophy with mild to moderate intraoral dysfunction.44
Muscle Transposition Techniques
All of the aforementioned neural techniques rely on the presence of a functional distal neuromuscular unit. When the distal neuromuscular unit is deficient, as in congenital facial paralysis or in situations in which reconstruction is not undertaken until 2 to 3 years after the original insult, muscle transposition is considered. Muscle transposition techniques require intense muscular retraining to achieve the intended dynamics. A classic muscle dynamic facial sling uses the temporalis muscle, innervated by the trigeminal nerve and perfused by the deep temporal branch of the internal maxillary artery. The muscle is released along with its aponeurosis from the temporal fusion line, reflected inferomedially, and attached to the modiolus at the oral commissure, the nasolabial fold, and potentially the orbicularis oculi. Disadvantages include lack of spontaneous movement, temporomandibular joint dysfunction, and soft tissue fullness over the zygomatic arch. Other transferable muscle units include the masseter muscle and the anterior belly of the digastric muscle.44
Innervated Free Tissue Transfer
Microsurgical free innervated muscle transfer may be considered in the same situations as local muscle transfers but is especially appropriate when concomitant soft tissue augmentation is needed. Muscles described for this purpose include the gracilis, latissimus dorsi, serratus anterior, and pectoralis minor muscles. The procedure may be performed in a single stage if the proximal facial nerve stump is available for anastomosis or if a long enough donor muscle nerve is present to reach the contralateral facial nerve branches. Often, however, it is a staged procedure beginning with establishment of a local neural source via cross-facial nerve grafting. The extent of axonal regeneration through the graft is monitored using Tinel’s test. After sufficient axonal progression, approximately 6 to 12 months, the free muscle transfer is performed via vascular anastomoses to the superficial temporal or facial vessels, recipient and donor nerve coaptation, and fixation of the muscle to the zygoma superolaterally and to the nasolabial fold, upper lip orbicularis, and lower lip orbicularis inferomedially. Disadvantages of free muscle transfer include donor site morbidity, lengthy surgical times, and the need for specialized microsurgical skills.
One of the most important goals of treatment for facial paralysis is rehabilitation of the periocular region. This objective may be simply achieved with implantation of gold or platinum upper eyelid weights, which allows gravity to assist with lid closure. Static fascial slings are used to improve symmetry when comorbid conditions preclude more extensive and staged surgeries. Sling materials include tensor fasciae latae, Gore-Tex, and human acellular dermal allograft. Nonsurgical techniques play a significant role in improving facial symmetry, both as a primary intervention and an adjunct to surgery. Contralateral mimetic muscle hypertonicity is tempered with botulinum toxin injections. Finally, soft tissue rejuvenative techniques such as cervicofacial rhytidectomy, blepharoplasty, browlift, and midface lift can improve the soft tissue effects of facial nerve paralysis (Fig. 45-40).
Facial reanimation treatment algorithm.
Breast cancer is the most common malignancy and the second leading cause of cancer-related death among women in the United States. One in eight women will develop breast cancer sometime during their life. Breast reconstruction began as a means to reduce chest wall complications and deformities from mastectomy. Reconstruction has now been shown to benefit women in terms of psychological well-being and quality of life.45 The goal of breast reconstruction is to re-create form and symmetry while avoiding delay in adjuvant cancer treatment. A number of studies have shown that breast reconstruction, both immediate and delayed, does not impede standard oncologic treatment, does not delay detection of recurrent cancer, and does not change the overall mortality associated with the disease.46,47,48
Preoperative counseling of the breast cancer patient regarding reconstruction options should include discussion of the timing and type of reconstruction, alternatives to surgical reconstruction, and realistic expectations. The plastic surgeon and surgical oncologist must maintain close communication to achieve optimal results.
Immediate reconstruction is defined as initiation of the breast reconstructive process at the time of the ablative surgery. This is usually done in patients with early-stage disease for whom there is low expectation of postoperative radiation therapy. Immediate reconstruction takes advantage of the preserved, supple skin envelope made possible by the skin-sparing mastectomy approach. In general, this allows a more aesthetically pleasing and symmetric reconstruction. It is also psychologically advantageous to the patient to avoid living with the mastectomy deformity, as in delayed reconstruction. Furthermore, the cost to the medical system is less with immediate reconstruction because fewer operations are required than for staged procedures. Disadvantages include the potential delay of adjuvant therapy due to surgical site complication, partial necrosis of mastectomy skin flaps, and the possibility that unanticipated postoperative radiation therapy is required. Breast reconstructions by all techniques are adversely affected by radiation therapy, and many surgeons feel reconstruction should be delayed until at least 6 months after treatment.
Delayed breast reconstruction is initiated at least 3 to 6 months after mastectomy. This approach avoids mastectomy flap unreliability and radiation therapy unpredictability. However, the patient is subjected to an additional operative procedure, and overall cosmetic result is often worse (especially with autologous tissue reconstruction).
Partial Breast Reconstruction
Over the last decade, many women have chosen breast conservation therapy (BCT) consisting of segmental mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection combined with postoperative whole-breast irradiation. Although this less invasive cancer treatment is quite beneficial to many women, significant breast deformity can result from the tissue removal and radiation-induced changes, especially in women with small breasts. Oncoplastic surgery refers to the set of techniques developed to lessen breast deformity from partial mastectomy, both in the delayed and the immediate settings. One of the most common methods of minimizing defect visibility in large-breasted women is to rearrange the breast parenchyma at the time of tumor extirpation using reduction mammoplasty techniques. Dermatoglandular pedicles supporting the nipple-areolar complex can be designed in any number of orientations to avoid the defect location. This procedure, combined with traditional contralateral breast reduction, can result in excellent cosmetic outcomes, often better than the preoperative appearance (Fig. 45-41). The lateral thoracodorsal flap, based on the lateral intercostal perforators at the inframammary fold, is particularly useful in correcting lateral breast defects49
Preoperative (top row) and 3-week postoperative (bottom row) photos of a 52-year-old patient with cancer at the 6 o’clock position of the left breast. Oncoplastic superomedial pedicle reduction on the left breast was performed simultaneously with a left segmental mastectomy of the lesion and a contralateral symmetrization reduction. (Photographs reproduced with permission from M. Gimbel.)
One drawback of these oncoplastic techniques when performed at the time of segmental mastectomy is the chance that, if the specimen margins are not clear, the reconstruction must be taken down to allow for reexcision. The oncologic implications of reusing the flap in this setting are unclear. Another shortcoming is the potential for fat necrosis, especially distally, in these nonaxial pattern flaps.
By necessity or patient choice, many women undergo mastectomy for local control of breast cancer. In fact, recently in response to the increased recognition of multifocal disease and experience with poor aesthetic results after BCT in small-breasted patients, some women have chosen mastectomy despite being candidates for BCT. The simplest method of reconstructing the breast is placement of an implant into the mastectomy defect. Occasionally an implant may be placed at the time of mastectomy as a one-stage mound reconstruction. Usually, however, the first stage involves placement of a silicone shell tissue expander under the chest wall musculature (pectoralis major, serratus anterior, superior rectus sheath), followed by expansion of the skin and pocket regularly over the following few months. The patient then returns to the operating room for removal of the expander and placement of a saline or silicone breast implant (Figs. 45-42 and 45-43). After exhaustive investigation, silicone implants have been proven as safe and effective as saline implants in breast augmentation and reconstruction. After another few months, the nipple is reconstructed.
Tissue expansion and implant-based breast reconstruction. (Illustrations reproduced with permission from M. Gimbel.)
Bilateral tissue expander/implant–based breast reconstruction. Appearance preoperatively (A) and 2 months after saline implant exchange (B). (Photographs reproduced with permission from M. Gimbel.)
The advantages of the tissue expander/implant–based reconstruction are absence of donor site morbidity, short operative times, and short recovery periods. The disadvantages include the need for more reconstructive stages and longer cumulative time to completion of reconstruction. Implant breast reconstructions tend to lack the natural breast feel and ptotic appearance. This is particularly noticeable in unilateral reconstructions. Some of these disadvantages have been mitigated by the advent of nipple-sparing mastectomy and immediate, acellular dermal matrix-assisted implant reconstruction (Fig. 45-44). Complications related to prosthetic-based breast reconstruction include infection, malposition, hematoma, seroma, and rupture and deflation. Long term, the most common problem requiring reoperation is the formation of dense scarring around the implant (capsular contracture) causing firmness, visible deformity, and even discomfort. In addition, implants are medical devices that undergo mechanical wear, ultimately leading to leakage and deflation. All in all, the chance that a woman will need additional unanticipated surgery on her reconstructed breast within 5 years of prosthetic-based reconstruction is approximately 35%.50 The cosmetic results worsen and the rate of complications increases when implants are placed in an irradiated chest wall, regardless of whether the radiation therapy occurs before or after reconstruction.
Immediate single-stage implant-based breast reconstruction after bilateral prophylactic nipple-sparing mastectomy (NSM). A. Preoperative photo. B. Postoperative photo after bilateral NSM and immediate acellular dermal matrix-assisted silicone gel implant reconstruction. (Photographs reproduced with permission from M. Gimbel.)
Total Autologous Tissue Reconstruction
An entirely different way to reconstruct the breast avoids the placement of implants in favor of using only the patient’s own redundant tissue. Indications for total autologous breast reconstruction are many and varied, including patient preference, previous or anticipated chest wall radiation treatment, a ptotic contralateral breast, and previous failed implant reconstruction. Contraindications are lack of a suitable donor site due to scarring or minimal adiposity, morbid obesity, and serious comorbidities that preclude a longer surgery and recovery period.
The most commonly used donor site is the abdomen. Most women in the breast cancer patient population have redundant skin and fat in the lower abdomen that may be transferred to the chest wall and fashioned into a breast mound. Many techniques have been developed to transfer this tissue, both as pedicled myocutaneous flaps and as free flaps. The workhorse abdominal flap for breast reconstruction is the pedicled transverse rectus abdominis myocutaneous (TRAM) flap. This flap is based on the superior epigastric vessels that run on the undersurface of the rectus abdominis muscle. A transversely oriented skin paddle with underlying fat is isolated based on its perforating vessels that course through the rectus muscle to join the main superior epigastric pedicle. The flap, along with the rectus muscle and blood supply, is tunneled under the anterior chest wall and delivered into the mastectomy defect, where it is then shaped into a breast mound. The donor site is closed in a manner similar to an abdominoplasty. The advantages of this and all total autologous reconstruction techniques are creation of a breast that looks and feels natural, that changes volume along with the patient’s weight (and the contralateral natural breast), and that avoids the potential complications of breast implants. In addition, patients are often pleased to have the incidental benefit of an abdominoplasty. The pedicled TRAM flap procedure is also relatively quick for a total autologous reconstruction. Downsides include the potential for partial or complete flap failure, fat necrosis, fullness in the upper abdomen from the tunneled pedicle, abdominal wall bulge or hernia, and abdominal wall weakness.
The free TRAM flap was introduced to improve on the sometimes limited volume of tissue that can be carried by the relatively indirect blood supply of the pedicled TRAM’s superior epigastric vessels. The free TRAM flap is similar to the pedicled TRAM flap but is based on the deep inferior epigastric vessels, which are the dominant blood supply to the lower abdomen. The flap is harvested as a free flap, and the deep inferior epigastric artery and vein are anastomosed to recipient vessels in the chest, usually the internal mammary or the thoracodorsal vessels. A refinement to this method is the muscle-sparing free TRAM flap procedure, in which less fascia and rectus abdominis muscle is harvested with the flap to minimize donor site morbidity. The ultimate muscle-sparing free TRAM flap is the deep inferior epigastric perforator flap (Fig. 45-45). In this case, the fascia is opened but no muscle is included with the flap, and the perforating vessels of the deep inferior epigastric system are dissected between the muscle fibers to join the main pedicle. When patients are carefully selected, muscle-sparing techniques decrease abdominal wall morbidity and increase useful pedicle length for microsurgery without significantly compromising flap perfusion51 (Fig. 45-46A,B). Finally, in some patients, the lower abdominal tissue may be transferred to the breast as a free flap without violating the abdominal wall fascia at all. The superficial inferior epigastric artery is often capable of supporting enough abdominal tissue volume to reconstruct the breast. Because this artery and its accompanying vein do not traverse the anterior rectus sheath, the flap can be harvested with no more abdominal wall morbidity than an abdominoplasty. Unfortunately, this artery is frequently absent or too diminutive in size to be used in the majority of patients. Despite the many advantages of microsurgical total autologous breast reconstruction, it is associated with longer operative times than pedicled TRAM procedures, requires expertise in microsurgery, and has the potential for complete flap failure due to microvascular thrombosis.
Deep inferior epigastric perforator flap breast reconstruction. (Illustrations reproduced with permission from M. Gimbel.)
A. Left upper and lower panels: Free transverse rectus abdominis myocutaneous (FTRAM) flap and its donor site defect. Middle upper and lower panels: Muscle-sparing FTRAM flap and its donor site defect. Right upper and lower panels: Deep inferior epigastric perforator flap and its donor site defect. B. Preoperative and postoperative photos of a 43-year-old woman with a left muscle-sparing FTRAM breast reconstruction and right symmetrization reduction mammoplasty. (Photographs reproduced with permission from M. Gimbel.)
Implant and Autologous Tissue Reconstruction
The pedicled latissimus dorsi myocutaneous flap procedure is a straightforward, reliable method used for breast reconstruction. It is often reserved for reconstructing breasts when other methods have previously failed. The latissimus flap is relegated to second-choice status because it carries the major disadvantage of autologous tissue reconstruction (donor site morbidity) as well as all of the potential complications associated with breast implants. That aside, the latissimus flap/implant–based reconstruction can produce excellent cosmetic results with relatively low donor site morbidity (Fig. 45-47). The latissimus dorsi muscle with overlying skin paddle is elevated based on its thoracodorsal vessel pedicle, tunneled through the axilla, and delivered into the mastectomy site. After partial insetting, either a tissue expander or permanent implant is usually placed behind the muscle to give adequate volume to the reconstruction (Fig. 45-48). Drawbacks specific to this method include contour irregularity of the back, high rate of donor site seroma, and shoulder weakness (uncommon).
Preoperative and postoperative photos of a 58-year-old woman with a left latissimus dorsi flap/silicone implant breast reconstruction and right symmetrization mastopexy. (Photographs reproduced with permission from M. Gimbel.)
Latissimus dorsi flap/implant–based breast reconstruction. (Illustrations reproduced with permission from M. Gimbel.)
After creation of the breast mound, refinements and accessory procedures are performed after approximately 3 months. These may include breast mound revision, scar revisions, fat grafting, and nipple-areola complex reconstruction. Scores of methods have been described for reconstructing the nipple. These include local flap techniques (e.g., star flap, skate flap, C-V flap), grafting techniques (contralateral nipple/areola sharing, groin skin, labia skin), and tattooing.
With some notable exceptions, most surgeons advocate avoidance of implant-based breast reconstruction in chest walls that have previously received radiation or are likely to receive radiation due to the relatively high rate of complications and disappointing results. Delayed total autologous reconstructions bring healthy nonirradiated tissue to replace the damaged fibrotic tissue and are the preferred mode of breast reconstruction in this setting. Similarly, latissimus dorsi/implant reconstructions replace much of the irradiated skin, which probably explains to some degree why, in the face of previous irradiation, implants fair better with an overlying latissimus flap than without.
The question of whether total autologous reconstructions should be done before or after anticipated radiation therapy is still controversial. Those in favor of delaying the reconstruction argue that an irradiated flap will exhibit shrinkage and fibrosis that subtracts from the overall aesthetic result. Those in favor of performing immediate reconstruction in this setting feel that, because immediate reconstructions have inherently better aesthetics, the imperfect result due to irradiation it is still comparable to the result of delayed reconstruction without the additional operation. To date, no prospective study has been performed comparing the two approaches.
Trunk and Abdominal Reconstruction
In the trunk, as in most areas of the body, choice of reconstructive method is determined by the location and size of the defect and the properties of the deficient tissue. A distinction is made between partial-thickness and full-thickness defects in deciding between grafts, flaps, synthetic materials, or a combination of techniques. Unlike the head and the lower leg, the trunk harbors a relative wealth of regional transposable axial pattern flaps that allow sturdy reconstruction, only rarely requiring distant free tissue transfer. Indeed, the trunk serves as the body’s arsenal, providing its most robust flaps to rebuild its largest defects.
The chest wall is a rigid framework designed to resist both the negative pressure associated with respiration and the positive pressure from coughing and from transmitted intra-abdominal forces. Furthermore, it protects the heart, lungs, and great vessels from external trauma. Reconstructions of chest wall defects must emulate these functions.
The pectoralis major muscle is the workhorse pedicled flap for coverage of the sternum, upper chest, and neck. It is a Mathes and Nahai type V flap with one dominant pedicle (pectoral branch of the thoracoacromial artery) and several secondary segmental pedicles (intercostal perforators and the pectoral branch of the lateral thoracic artery).52 The muscle may be advanced or transposed on its dominant pedicle or used as a turnover flap based on its internal mammary perforators. Both methods are useful in covering the sternum after dehiscence or infection. Before the turnover flap is elevated, previous operative notes should be reviewed carefully to determine whether the internal mammary artery is still a viable perfusion source; the artery, especially the left, is frequently used for heart revascularization. The muscle may also be used for obliteration of intrathoracic dead space infections and as a myocutaneous flap for head and neck reconstruction. Although it is a reliable flap, the loss of the pectoralis major muscle results in upper extremity weakness and cosmetic deformity from loss of the anterior axillary fold.53
The rectus abdominis muscle is a type III axial pattern flap that can be based on the superior epigastric vessels or the deep inferior epigastric vessels.51 When elevated as a myocutaneous flap it can be designed with a transverse (TRAM) or vertical rectus abdominis myocutaneous skin paddle. Although the vertical rectus abdominis muscle flap has better vascularized skin due to its multiple longitudinally oriented perforators, the TRAM flap provides a larger area of donor skin that can be primarily closed with an easily concealable scar. The rectus abdominis muscle is frequently used for lower sternum reconstruction when the pectoralis muscle is insufficient. It can also be used in pedicle or free flap configuration for repair of large chest wall defects from cancer resection (Fig. 45-49).
Top row: Free transverse rectus abdominis muscle reconstruction of a large partial-thickness chest wall defect. Bottom row: Full-thickness chest wall defect reconstructed in two layers with human acellular dermal allograft and overlying pedicled vertical rectus abdominis muscle flap. (Photographs reproduced with permission from M. Gimbel.)
The latissimus dorsi myocutaneous flap is probably the most widely used flap in nonsternal chest wall reconstructions due to its broad size, location, reliability, and pedicle length. The flap is based on the thoracodorsal vessels arising from the subscapular system. Its secondary blood supply comes from the posterior intercostal and lumbar vessels.52 The arc of rotation of this flap can extend to most areas on the ipsilateral torso as well as to the abdomen, head and neck, and upper arm. The serratus anterior muscle can be included on the same vascular pedicle to further increase its surface area. Use of this donor site is relatively well tolerated, but shoulder weakness can be significant. The major drawbacks of the latissimus flap are its conspicuous scar and the high risk of seroma.53
The trapezius muscle flap, based on the transverse cervical vessels, is generally used as a pedicled flap to cover the upper midback, base of neck, and shoulder. The superior portion of the muscle along with the acromial attachment and spinal accessory nerve are preserved to maintain shoulder elevation function. Other useful flaps of the thoracic region include the scapular/parascapular fasciocutaneous flap, the external oblique flap, the medially or laterally based thoracoepigastric skin flaps, and the omental flap.
When a full-thickness defect of the chest wall involves more than two adjacent ribs, the inherent rigidity of soft tissue flaps may provide insufficient chest wall integrity. Although cadaveric bone and autologous bone grafts have been used in the past to lend structural support, the availability of well-tolerated synthetic and biologic materials has become more common. These materials include polypropylene (Prolene), polyethylene (Marlex), and polytetrafluoroethylene (Gore-Tex) meshes, methyl methacrylate, and acellular dermal allograft. Even if these avascular foreign bodies must be removed due to chronic infection, often a thick fibrous layer of tissue will have formed that can maintain chest wall stability.53
The abdominal wall also protects the internal vital organs from trauma, but with layers of strong torso-supporting muscles and fascia rather than with osseous structures. The goals of reconstruction are restoration of structural integrity, prevention of visceral eventration, and provision of dynamic muscular support. Defects in the abdominal wall may arise from trauma, oncologic resection, congenital deformities, and infection. By far the most common reason for abdominal wall deficiency, however, is incisional fascial dehiscence and herniation after laparotomy. When a reconstruction plan is being formulated, careful physical examination and review of the medical history will help prevent selection of an otherwise sound strategy that, because of previous incisions and trauma, is destined for failure.
Partial Defects of the Abdominal Wall
Large defects of the abdominal skin and subcutaneous tissue are usually easily controlled with skin grafts, local advancement flaps, or tissue expansion. Myofascial defects are more difficult to manage. The abdominal wall fascia requires a minimal-tension closure to avoid dehiscence, recurrent incisional hernia formation, or abdominal compartment syndrome.54 Prosthetic meshes are frequently used to replace the fascia in clean wounds and in operations that create myofascial defects. When the area of fascial deficiency is contaminated, as in infected mesh reconstructions, enterocutaneous fistulas, or viscus perforations, prosthetic mesh is avoided because of the risk of infection. A delayed reconstruction can be prefaced by insetting a resorbable polyglactin (Vicryl) mesh that will eventually granulate to allow skin grafting. The ensuing hernia is repaired later with prosthetics under cleaner conditions. The separation-of-components procedure has enjoyed much success in closing large midline defects without resorting to mesh. This procedure involves advancement of bilateral myofascial flaps consisting of the anterior rectus fascia/rectus abdominis/internal oblique/transversus abdominis muscle complex. Mobility of this myofascial unit is created by release of the external oblique muscle at the semilunate line. Midline defects measuring up to 10 cm superiorly, 18 cm centrally, and 8 cm inferiorly can be closed using separation of components.55 This technique is less effective in closing lateral defects, for which regional muscle and fascial flaps are usually better suited (rectus abdominis flap, internal oblique flap, external oblique flap).54
Full-thickness abdominal defects and large myofascial defects require large robust pedicled flaps or free flaps for closure. The tensor fasciae latae pedicled flap, based on the ascending branch of the lateral circumflex femoral vessels, is useful in reconstructing the lower two-thirds of the abdomen. Bilateral flaps can be used for very large defects, although the skin-grafted donor site is unsightly. The rectus femoris flap and the vastus lateralis flap can be used for smaller lower abdominal defects. The “mutton-chop” flap, which is an extended rectus femoris flap with fascia lata included distally, has been used successfully in closing massive defects.56,57 Large defects of the upper abdominal wall may be repaired with pedicled extended latissimus dorsi flaps with attached pregluteal fascia. Very large full-thickness defects, especially superiorly, are best treated with free tissue transfer of large myofascial units such as the latissimus dorsi or the tensor fasciae latae. These can also be innervated flaps to reestablish contractile force and strength in the abdominal wall.
With the beginnings of modern orthopedic and plastic surgery, improvements in the understanding of anesthesia, trauma resuscitation, infection, and the availability of early antibiotics, the requirement to amputate almost all open (compound) lower extremity fractures as a life-saving procedure gradually decreased while attempts at limb salvage became more realistic. The introduction and maturation of microsurgical techniques witnessed increasing successes in distal extremity replantations and free flap reconstructions. Soft tissue reconstruction thus advanced alongside evolving techniques of bone fixation, joint reconstruction, general vascular surgery, and acute multitrauma management. Current lower extremity reconstruction incorporates the use of vascularized bone, bone distraction techniques, composite tissue flaps, and functioning muscle transfers tailored to the given defect.58 The future may behold the use of cadaveric vascularized composite allografts or even tissue-engineered vascularized composite tissue constructs.
Common causes of high-energy lower extremity trauma include road traffic accidents, falls from a height, direct blows, sports injuries, and gunshots. Understanding the anatomy of the lower limb compartments, nerve and vascular supplies, muscle functions, skeletal structure, and mechanics is essential for accurate bony and soft tissue restoration for function and appearance. Several limb-salvage scoring systems have been suggested to aid in the decision regarding whether to amputate or attempt limb salvage, but their routine use remains controversial; nevertheless, they can provide guidance during this life-altering decision process.59 Compound fractures are often classified according to the system devised by Gustilo and colleagues (Table 45-12).60
Table 45-12Gustilo and Anderson classification of compound fractures ||Download (.pdf) Table 45-12 Gustilo and Anderson classification of compound fractures
|CLASSIFICATION ||DESCRIPTION |
|Grade I ||Wound <1 cm; minimal contamination, comminution, and soft tissue damage |
|Grade II ||Wound >1 cm; moderate soft tissue damage and minimal periosteal stripping |
|Grade IIIa ||Substantial contamination and severe soft tissue damage but adequate fracture coverage; usually due to high-energy trauma |
|Grade IIIb ||Substantial contamination, periosteal stripping, severe soft tissue damage, and inadequate fracture coverage; usually due to high-energy trauma |
|Grade IIIc ||Any open fracture with an associated arterial injury requiring repair |
In addition to following standard multiple trauma evaluation and resuscitation guidelines, the multidisciplinary team must assess the injured limb for neurovascular status, soft tissue defects and degloving, configuration of fractures, and presence of compartment syndrome. Neurovascular status and evidence for compartment syndrome require frequent reassessment, particularly following interventions such as fracture reduction, splintage, and surgery. Bony stabilization may be critical to controlling fracture hemorrhage. Doppler ultrasound examination may help assess vascular integrity. Angiography is a lengthier procedure that provides more detailed information, but the team must be cognizant that delay to revascularization increases the risk of massive reperfusion injury and multiple organ failure.61 Compartment syndrome must be released with urgent fasciotomies when present. Its most critical early feature is increasingly severe pain especially on passive stretch of the compartment’s musculature; pulselessness, pallor, paresthesia, and paralysis are late signs. Compartment pressure monitors are useful in patients who are unconscious or have proximal nerve blocks in place. Antitetanus vaccine and antibiotics should be provided as soon as possible according to contemporary guidelines.62 An evaluation of the patient as a whole allows treatment to be planned within the context of comorbidities, socioeconomic considerations, and rehabilitative potential. The loss of plantar sensation historically favored below-knee amputation, but this is no longer an absolute recommendation.61
With the availability of microvascular free tissue transplantation, radical débridement (i.e., wound excision) can be adequate even for the largest wound. Early one-stage wound coverage and bony reconstruction is generally advocated and should be performed jointly by extremity trauma orthopedic and plastic surgical teams whenever possible.61,62 It is reasonable for reconstruction to be deferred briefly if there remain tissues of questionable viability so that these can be reassessed and débrided as required. Placement of a temporary negative pressure dressing between débridements helps reduce bacterial ingress and the inflammatory response. If débridement produces an irregular dead space that cannot be completely obliterated, or if tissues remain questionable even after a second look, the resultant cavity may be filled with antibiotic-impregnated beads or available vascularized soft tissues to act as a spacer until definitive reconstruction is possible. This applies also to segmental bone losses within a soft tissue envelope of doubtful viability. In these situations, soft tissue coverage preferably is still achieved early; bony reconstruction can be completed at a later date, when both the bone and soft tissue envelope are stable and healthy. It remains debated whether fasciocutaneous or muscular flaps are superior for treating compound fractures. Dead space is critical to obliterate, and this is more readily achieved using muscle. Fasciocutaneous flaps may be superior for coverage of metaphyseal fractures, particularly around the ankle. Reviewed experimental data in animals suggest that diaphyseal tibial fractures with periosteal stripping are better covered by muscle instead of fasciocutaneous flaps.63 Perforator-based chimeric flaps, such as the anterolateral thigh flap with a chimeric portion of vastus lateralis, can be designed to incorporate the best features of both tissue types for the given defect.
Once meticulous débridement is complete, the order of surgical repair is fracture stabilization followed by vascular repair and reconstruction of a stable soft tissue envelope. The choice of method for soft tissue coverage is determined by the location and extent of the injury (Table 45-13). Coverage for weight-bearing areas should be durable, stable (nonshearing), and sensate. Properly fitted footwear provides essential protection against pressure-related complications. Split-thickness skin grafts are reasonable for coverage of exposed healthy muscle or soft tissue. Local flaps may be used to cover smaller defects. Island pedicled perforator-based flaps are more versatile in design and inset, preserve viable muscles by excluding them from flap harvest, and can be a useful option when there is no significant degloving injury (Fig. 45-50). Using retrograde pedicle dissection, they can be harvested in freestyle fashion both to avoid the zone of injury and to suit the defect requirements.64 Free tissue transplantation is preferred for larger or more complex defects, particularly in the middle and lower thirds of the leg where there are less soft tissues available for reconstruction. Free flaps need not be limited to providing only soft tissue coverage; incorporation of vascularized bone, such as of fibula or iliac crest, can aid in fracture management.65 Chimeric flap configurations can improve flap insetting into composite defects. Flow-through designs, such as the anterolateral thigh flow-through free flap, can be used to bridge segmental vascular defects to revascularize the distal extremity.66 Muscular flaps can be motor innervated to restore lost muscle functions at the recipient site.67 Other techniques such as bone distraction and tissue expansion may be indicated in select circumstances. Traditional cross-leg flaps are almost never used now; they cause complete immobilization and increase the risk of deep vein thrombosis and contracture formation.
Table 45-13Some lower extremity reconstructive options for soft tissue coverage after fracture ||Download (.pdf) Table 45-13 Some lower extremity reconstructive options for soft tissue coverage after fracture
|AREA OF DEFECT ||RECONSTRUCTIVE OPTIONS |
|Femur ||Sartorius muscle/MC flap (anterior defects) |
| ||TFL muscle/MC flap (posterior defects) |
| ||Vastus lateralis/medialis muscle/MC (mid to lower thigh defects) |
| ||ALT/AMT and posterior thigh fasciocutaneous flap |
| ||Free osseous flaps (e.g., double-barreled fibula osteoseptocutaneous flap) useful for segmental femur defects |
|Knee and proximal third of tibia ||Gastrocnemius muscle (medial or lateral head, or both) with SSG |
| ||Island pedicled fasciocutaneous flaps (e.g., distally based anterolateral thigh flap; medial sural artery perforator flap) |
| ||Free tissue transfer for larger defects |
|Middle third of tibia ||Soleus muscle with SSG |
| ||Gastrocnemius head(s) with SSG |
| ||Tibialis anterior muscle “open-book flap” (preserves function) |
| ||Island pedicled fasciocutaneous flaps (e.g., posterior tibial and peroneal perforator flaps) |
| ||Free tissue transfer for larger defects |
|Distal third of tibia ||Free tissue transfer usually the first choice |
| ||Reverse flow sural neurofasciocutaneous flap |
| ||Island pedicled fasciocutaneous flaps (e.g., posterior tibial and peroneal perforator flaps) |
| ||Local muscle flaps for smaller defects |
Perforator-based island pedicled anterolateral thigh flap for soft tissue coverage of the upper third lateral leg. A. Soft tissue defect with exposed tibial metaphysis after débridement. Note the arterial handheld Doppler signal (red dot) around which the flap has been designed. The flap has been reverse-planned and the pivot point determined along the axis of the descending branch of the lateral circumflex femoral artery (black line). B. The flap has been harvested and its pedicle skeletonized to maximize freedom of flap motion; note the additional backup vein in case venous supercharge might be required. C. Satisfactory flap perfusion following inset. D. Flap perfusion became compromised postoperatively but (E) improved with bedside maneuvers; if improvement did not occur, backup venous supercharge would have been available. F. The regional fasciocutaneous flap has provided durable, color- and texture-matched soft tissues for reconstruction around the knee; importantly, the pliability of the flap tissues has allowed for a full range of knee movement to be maintained. (Photographs reproduced with permission from L. Lin.)
Osteomyelitis often complicates inadequately débrided compound leg fractures. Delayed coverage also appears to increase the risk of this dreaded complication. Generous irrigation, débridement, removal of dead bone (even in a segment), expedient antibiotic therapy, and healthy soft tissue coverage are important in both acute compound fracture and established posttraumatic osteomyelitis. Large segmental bone losses can be addressed with microvascular free transplantation of osseous flaps or distraction lengthening.61,68
When limb salvage either is not possible or is not in the best interests of the patient, attention is directed to providing soft tissue stump coverage suitable for weight bearing and allowing ambulation with a properly fitted prosthesis. Ideally, local tissues are used; however, when they are unavailable or inadequate, the amputated part can be a useful source of skin grafts or tissues for microvascular free transfers to the stump, which preserves length and avoids a more proximal amputation.
Reconstruction after Oncologic Resection
The refinements in surgical ablation techniques, in adjuvant radiation therapy and chemotherapy, and in limb reconstruction methods have opened the possibility for curative limb-sparing treatments instead of amputation. Extensive soft tissue and segmental long bone defects from radical tumor resection and radiation-compromised wound healing can often be reconstructed now by liberal importation of fresh tissues through microvascular free tissue transplantation tailored to the defect.
The pathophysiology of primary diabetic lower limb complications has three main components: peripheral neuropathy (motor, sensory, and autonomic), peripheral vascular disease, and immunodeficiency. Altered foot biomechanics and gait caused by painless collapse of ligamentous support, foot joints, and foot arches change weight-bearing patterns. Blunted pain allows cutaneous fissuring and ulceration to progress. Multiflora infections are established amid local immunodeficiency and microvasculopathy. Frank neuroarthropathic Charcot’s foot deformities may ultimately result. Cutaneous ulcerations may chronically deteriorate relatively painlessly, involving deeper tissues, including bone. Persistent soft tissue infection and osteomyelitis, worsened by peripheral vascular compromise and immunodeficiency, traditionally ends in gangrene and amputation. More than 60% of nontraumatic lower extremity amputations occur in diabetics.69 Indeed, the age-adjusted lower extremity amputation rate in diabetics (5.5 per 1000 diabetics) was approximately 28 times that of people without diabetes (0.2 per 1000 people).69 Improved patient education and medical management, timelier detection of diabetic foot problems and referral for treatment, and the use of more refined techniques for wound management play important roles in improving the chances of limb preservation.70
Diabetic patients with lower limb disease often have significant multisystemic comorbidities that must be optimized for surgery; strict perioperative control of blood glucose levels is mandatory. Clinical examination must include documentation of sensory deficits, vascular insufficiencies, and evidence of osteomyelitis. Plain radiographs, MRI, nuclear bone scans, and angiography or duplex imaging may be indicated. A patient with significant vascular disease may be a candidate for lower extremity endovascular revascularization or open bypass.71 Nerve conduction studies may diagnose surgically reversible neuropathies at compressive sites and aid in decisions about whether to perform sensory nerve transfers to restore plantar sensibility.70 Antibiotic and fungal therapies should be guided by tissue culture results.
Plastic surgical management starts with thorough débridement of devitalized or infected tissues, purulent cavities, and osteomyelitic bone. Methods of wound closure are dictated by the extent and location of the postdébridement defect (Table 45-14). Vacuum-assisted closure may be appropriate for superficial defects. Skin grafts should be used cautiously and not in weight-bearing areas. Local and regional flaps can be used after careful evaluation of their vascularity given concurrent peripheral vascular disease and possible recent distal vascular bypass procedures. Microvascular free tissue transfers are appropriate when defects are large or when local flaps are not available. Combination lower extremity bypass and free flap coverage has proved beneficial for the treatment of the diabetic foot in terms of healing and reduction of disease progression.72 Orthopedic surgeons should be consulted to improve foot biomechanics and address bony prominences to reduce the risk of recurrent ulceration. Proper footwear (including orthotic devices and off-loading shoe inserts), hygiene, and toenail and skin care are essential.70
Table 45-14Some reconstructive options for the diabetic foot ||Download (.pdf) Table 45-14 Some reconstructive options for the diabetic foot
|AREA OF DEFECT ||RECONSTRUCTIVE OPTIONS |
|Forefoot ||V-Y advancement |
| ||Toe island flap |
| ||Single toe amputation |
| ||Lisfranc’s amputation |
|Midfoot ||V-Y advancement |
| ||Toe island flap |
| ||Medial plantar artery flap |
| ||Free tissue transfer |
| ||Transmetatarsal amputation |
|Hindfoot ||Lateral calcaneal artery flap |
| ||Reversed sural artery flap |
| ||Medial plantar artery flap ± flexor digitorum brevis |
| ||Abductor hallucis muscle flap |
| ||Abductor digiti minimi muscle flap |
| ||Free tissue transfer |
| ||Syme’s amputation |
|Foot dorsum ||Supramalleolar flap |
| ||Reversed sural artery flap |
| ||Thinner free flaps (e.g., temporoparietal fascia, radial forearm, groin, thinned anterolateral thigh flaps) |
The lymphatic system provides a high-volume transport mechanism, clearing proteins and lipids from the interstitial space to the systemic vasculature by means of differential pressure gradients. Factors that contribute to circulatory lymphatic flow include segmental lymphangion contractility, skeletal muscle activity, and one-way valves that prevent backflow.73,74 The lymphatics course throughout the body alongside the venous system, into which they eventually drain via the major thoracic and cervical ducts. With lymphatic obstruction, abnormal connections form between the superficial and deep lymphatics and between the lymphatic and venous systems. Lymphatic stagnation, hypertension, and valvular incompetence contribute to edema, inflammatory fibrovascular proliferation, and collagen deposition, causing firm, nonpitting swelling with peau d’orange cutaneous changes. Lymphoscintigraphy reveals the lymphatic anatomy and quantifies lymphatic flow. MRI provides anatomic information regarding lymphatic trunks, nodes, and obstructive lesions. It is essential to rule out neoplastic lymphatic invasion, especially after oncologic ablation, as a cause of secondary lymphedema. Lymphangiosarcoma is a rare cause of lymphedema that is deadly if diagnosed late.75
Primary lymphatic obstruction may arise from congenital malformations of the lymphatic system such as lymphatic hypoplasia, functional insufficiency, or absence of lymphatic valves. Identified genetic causes include the autosomal dominant Milroy’s disease. Lymphedema praecox accounts for >90% of cases of primary lymphedema, generally appears during puberty but sometimes as late as the third decade, and occurs more commonly in females. It is usually unilateral and limited to the foot and calf. Lymphedema tarda appears after the age of 35 years and is relatively rare. Secondary (acquired) lymphedema is much more common, with filariasis being the leading cause worldwide.76 In Western countries, secondary lymphedema is more commonly the result of neoplasms and their surgical treatments and radiotherapy.76
The mainstays of management for lower extremity lymphedema are patient education and nonsurgical measures, including one or more of the following: use of external compressive garments and devices, limb elevation, administration of antibiotics for episodes of cellulitis, and specialized complex physical therapy.77,78 Until recently, the efficacy of available surgical options was generally poor, so they were reserved for cases in which aggressive nonsurgical measures had failed. The classic Charles procedure involved radical excision of lymphedematous suprafascial tissues with skin grafting for coverage; cosmetic outcomes were often disastrous, and functional problems arose due to high rates of contracture, wound breakdown, and ulcerations. This method was later modified into multiple staged excisions of subcutaneous tissues. Other techniques include liposuction and bridging procedures.78 Microsurgical lymphatic-lymphatic, lymphatic-venous, lymphatic-venous-lymphatic, and lymph node–venous anastomoses were all tried historically, with some techniques showing efficacy early on but long-term results showing high variability.79 Recently, however, with an increased understanding of its pathophysiology and improved preoperative investigations, objective staging of lymphedema severity has become more accurate and allowed microsurgeons to tailor treatments for properly selected patients.80,81 These factors, alongside improvements in microsurgical techniques, instrumentation, and long-term postoperative care, have provided better surgical results and a resurgence in interest in microsurgical treatment for lymphedema.76 Nonsurgical techniques can be, and usually are, combined with any of the surgical methods.
A pressure ulcer is defined as tissue injury, usually over a bony prominence, due to pressure or a combination of pressure and shear forces. These wounds occur in patients debilitated by age, illness, immobilization from orthopedic injuries, or spinal cord injury. Prevention of pressure ulcers first requires identification of susceptible patients. Once such patients are identified, measures to prevent development of ulceration include frequent position changes (by both the patient and caretakers), use of pressure reduction equipment (low air loss mattresses and seat cushions, heel protectors), nutritional optimization, hygienic control of incontinence, and medical and/or surgical treatment of muscle spasm and joint contracture. Once an ulcer has developed, these same factors must be carefully evaluated and deficiencies corrected before embarking on a complex reconstructive treatment plan. Successful reconstruction also requires a medically stable, cooperative, motivated patient with adequate social support.
Pressure ulcers are described by their stage, based on depth of tissue injury (Table 45-15).82 Stage I and II ulcers are treated conservatively with dressing changes and basic pressure ulcer prevention strategies as already discussed. Patients with stage III or IV ulcers should be evaluated for surgery. The wound is examined for soft tissue infection or abscess, osteomyelitis, and involvement of deeper structures or spaces (e.g., joint space, urethra, spinal canal) to determine the urgency and specific requirements of the problem. Blood laboratory work and imaging studies are performed to help establish whether soft tissue or bone infection is present. Radiographs are usually adequate to rule out osteomyelitis; CT and MRI are helpful when plain films are equivocal. Wet gangrenous tissue and abscesses should be surgically débrided without delay to prevent or treat sepsis. In patients who do not meet the strict reconstruction criteria, débridement to healthy tissue without subsequent reconstruction may be the optimal treatment. If bone is present at the wound base, it should be débrided only to bleeding bone and left with a smooth contour. Complete ischiectomy should not be performed for ischial decubitus ulcers, because removal of one ischium only transfers subsequent pressure trauma to the contralateral ischium or the perineum. If osteomyelitis is present, which is best proven by culture of specimens obtained by intraoperative bone biopsy, long-term antibiotic therapy guided by microorganism sensitivity is indicated. A special note should be made regarding surgical treatment of spinal cord injury patients with T5 or higher injuries. In these patients, manipulation of a pressure ulcer and even simple urinary retention can trigger autonomic hyperreflexia. This dangerous condition is characterized by critically high blood pressure elevation and sympathetic discharge. Effective management is immediate recognition and reversal of trigger factors along with prompt administration of pharmacologic agents to prevent complications such as intracranial and retinal hemorrhage, seizure, cardiac irregularities, and death.
Table 45-15National pressure ulcer advisory panel staging system ||Download (.pdf) Table 45-15 National pressure ulcer advisory panel staging system
|CLASSIFICATION ||DESCRIPTION |
|Stage I ||Intact skin with nonblanchable redness |
|Stage II ||Partial-thickness loss of dermis; may present as blister |
|Stage III ||Full-thickness loss of dermis with visible subcutaneous fat (no deeper structures exposed) |
|Stage IV ||Full-thickness loss of dermis with exposed bone, tendon, or muscle |
|Unstageable ||Full-thickness loss of dermis with ulcer base obscured by eschar |
Direct closure of a pressure ulcer is rarely performed because it usually creates tension in the healing tissues already stressed by nonphysiologic external pressure, predisposing the closure to breakdown. Skin grafting is useful for shallow ulcers with well-vascularized beds that are not subjected to high mechanical shear. Unfortunately, these requirements remove most pressure ulcers from skin graft candidacy. The mainstay of deep pressure ulcer reconstruction is coverage with well-vascularized local flaps. There is debate over whether myocutaneous flaps are better than fasciocutaneous flaps for resurfacing regions prone to excess pressure and shear. Although myocutaneous flaps have excellent bulk and blood supply, muscle has low tolerance for ischemic injury. From an anatomic viewpoint, there is no pressure point on the human body where bone is padded by muscle. On the other hand, although fasciocutaneous flaps provide reasonable bulk and are teleologically appropriate, some argue that subcutaneous fat and fascia have low resistance to pressure and shear forces and have less robust perfusion than muscle.83
The anatomic location of the pressure ulcer naturally has a profound impact on flap choice. Regardless of the wound site, however, the flap design should be very large, more than needed for closure, so that if the ulcer recurs the flap can be readvanced. In addition, care should be taken to place suture lines, the weakest part of the reconstruction, away from pressure points. Over the last few decades, patterns have developed in the selection of particular flaps for particular pressure sores. Sacral decubiti are well treated with gluteus maximus myocutaneous flaps (Fig. 45-51). In ambulatory patients, either the superior or the inferior gluteus muscle is spared to preserve hip extension function. The downside of using the gluteal muscle is the relatively bloody dissection. A common alternative is the gluteal fasciocutaneous advancement or rotational flap. Ischial pressure sores are generally due to sitting in a wheelchair with improper cushioning or insufficient position changes. A good first-choice flap for ischial wound reconstruction is the hamstring V-Y myocutaneous flap. The gluteus maximus flap may also be transposed inferiorly to cover this wound. A fasciocutaneous alternative is the posterior thigh flap, based on the continuation of the inferior gluteal artery. Trochanteric ulcers develop from prolonged positioning in the lateral decubitus position or from poorly fitting seat or wheelchair equipment. The tensor fasciae latae myocutaneous flap is an expendable muscle unit in ambulatory patients that has a reliable blood supply. It can be advanced superiorly or transposed on its long arc of rotation (see Fig. 45-51). Good second-choice flaps are the rectus femoris muscle flap and the vastus lateralis myocutaneous flap. When pressure sores are neglected, they can become confluent, forming large areas of deep tissue destruction. This dire situation may require hip disarticulation and use of the upper leg soft tissue as a total thigh flap for coverage.
Flap reconstruction of pressure ulcers. Top row: Preoperative and 1-month postoperative photos of a stage IV sacral decubitus ulcer treated with a myocutaneous gluteus maximus flap. Bottom row: Preoperative and 1-month postoperative photos of a stage IV trochanteric ulcer treated with a myocutaneous V-Y tensor fasciae latae flap. (Photographs reproduced with permission from M. Gimbel.)
The postoperative care after flap reconstruction of pressure ulcers is as important for success as the surgery itself. The authors recommend transfer of the patient from the operating room table onto an air-fluidized bed, where the patient will remain for the next 7 to 10 days in the hospital. Meticulous instructions must be given to the nursing staff and therapists regarding the positioning and rolling of the patient to prevent stressing the suture lines during these maneuvers. Nutrition and muscle spasm control are carefully maintained. The posthospitalization care plan, which should have been arranged preoperatively, is confirmed to avoid lapses in proper care. Patients with ischial sores are advised to abstain from sitting for 6 weeks to allow for sufficient healing. Care of the pressure ulcer patient is a labor-intensive process that requires attention to detail by the surgeon, nurses, therapists, caseworkers, and family. Unfortunately, small gaps in care inevitably lead to large gaps in the debilitated patient’s integument.
Reconstructive Transplant Surgery
Composite tissue allotransplantation (CTA), such as hand and face transplantation, has become a clinical reality and offers enormous potential for many reconstructive problems, including amputation of extremities. However, as with solid organ transplantation, there remains the issue of allograft rejection. In contrast to visceral organ transplantation, which involves homogeneous tissues, CTA may involve a combination of skin, subcutaneous tissue, nerve, blood vessels, muscle, tendon, and bone, and thus carry the antigenicities of all these tissue types. The basic principles of immunosuppression for solid organ transplantation have been applied to CTA and include therapy with a variety of combinations of T-cell–depleting agents, monoclonal antibodies, calcineurin inhibitors, antimetabolites, and rapamycin. The complications associated with immunosuppression are well known, including opportunistic infections, metabolic disturbances, and malignancies. Patients selected to undergo CTA, specifically hand transplantation, are young and healthy and therefore more resistant to immunosuppressive side effects than typically less robust solid organ recipients.
As with any surgical procedure, the benefits, success rate, and complications must be understood. Unlike solid organ transplantation, CTA is not a lifesaving procedure. There remains much debate over the risks associated with lifelong administration of potentially dangerous immunosuppressive agents to patients who have no life-threatening illness. The ultimate goal in CTA research is immune tolerance in which the recipient of the allograft remains fully immunocompetent yet does not mount an immunologic response to the transplanted allograft. Accomplishment of this goal would allow the decrease or possible elimination of immunosuppressive medications. If immune tolerance is achieved, CTA clinical applications will broaden dramatically as they become the next frontier in reconstructive surgery84 (Fig. 45-52).
Hemifacial composite tissue allotransplantation in a rat model. (Photographs reproduced with permission from K. McLean.)