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Anesthesia for upper extremity surgery

Synopsis ■ Optimal perioperative anesthetic outcomes are achieved by a thorough understanding of anatomy, pharmacology, techniques, and potential complications. ■ Local anesthetics (LA) make regional anesthesia possible by preventing the propagation of nerve conduction and by inhibiting or relieving pain. ■ Ultrasound guidance in the use of regional anesthesia has decreased the need for high volumes of anesthetic. ■ Use of wide-awake local anesthesia with no…

Diagnostic imaging of the hand and wrist

Synopsis ■ Radiographs form the cornerstone of diagnostic imaging of the hand and wrist, and are usually the first imaging modalities performed following clinical evaluation. ■ The keys to obtaining the most information from radiographs are ordering the correct radiographs for the situation, and ensuring the radiograph is appropriately taken. ■ A systematic and careful examination of the radiograph is necessary to glean the often subtle…

Examination of the upper extremity

Synopsis ■ Physical examination of the upper extremity starts with a detailed and accurate patient history. ■ Physical examination of the upper extremity consists of inspection, palpation, measurement of length, girth, and ranges of motion, assessment of stability, and detailed assessment of the associated nerve and vascular systems. ■ Thorough understanding of the anatomy, physiology, and biomechanics of the upper extremity is essential to perform a…

Anatomy and biomechanics of the hand

Synopsis ■ The hand is an incredibly designed structure with complex anatomy and precise biomechanics. The hand must be able to produce adequate force to allow performance of activities of daily living. Furthermore, it must ensure coordination of the fingers for precise prehension and fine motor tasks. ■ In order to achieve an optimal functional and aesthetic outcome in patients requiring hand surgery, it is thus…

Current options for nipple reconstruction

Introduction Reconstruction of the nipple–areolar complex (NAC) is most commonly performed for women as the final component of breast reconstruction following mastectomy to treat breast cancer. While a significant proportion of women ultimately forgo nipple reconstruction to avoid yet another procedure in the arduous battle against breast cancer, the majority of patients undergoing NAC reconstruction describe improved overall aesthetic and psychosocial satisfaction compared with breast reconstruction…

Total breast reconstruction by external vacuum expansion (EVE) and autologous fat transfer (AFT)

Introduction Breast reconstruction continues to evolve and has come a long way from having prosthetic implants as the sole option. Since the early 1980s, the pedicled transverse rectus abdominis muscle (TRAM) flap and its microvascular free flap refinement gave patients another option of totally autologous tissue breast reconstruction. These flaps highlighted the long-term benefits of using vascularized fat for breast reconstruction. This chapter is about a…

Robotic-assisted autologous breast reconstruction

Introduction Robotic surgical technology has become ubiquitous throughout the various fields of minimally invasive surgery owing to its enhanced precision, tremor elimination, motion scaling, high resolution, 3D optics, and a user-friendly interface. These unique features inspired the senior author to integrate it into plastic surgery, performing the first clinical cases beginning in 2009, and more specifically into breast reconstructive surgery. In this subspecialty, minimizing skin incisions,…

Breast reconstruction and radiotherapy: indications, techniques, and outcomes

Access video lecture content for this chapter online at Elsevier eBooks+ Introduction The treatment of breast cancer is constantly evolving. Surgery remains an important pillar, but the use of radiotherapy (RT) has increased dramatically due to its clinical benefit in reducing risk of locoregional recurrence and improving the overall survival rate in high-risk patients. Despite the oncological benefits of RT, most patients will experience adverse effects…

Surgical and non-surgical management of breast cancer-related lymphedema

Access video content for this chapter online at Elsevier eBooks+ Introduction Lymphedema is estimated to affect over 30 million patients in the US, with breast cancer being the most frequent cause. Incidence of breast cancer-related lymphedema (BCRL) can exceed 30% of patients undergoing axillary dissection and adjuvant radiotherapy. Few clinical guidelines exist for the management of lymphedema, thus for many years treatment was limited to conservative…

Oncoplastic breast reconstruction: local flap techniques

Introduction Breast reconstruction performed with a pedicled fasciocutaneous island flap from the back is a valuable tool in the armamentarium of the reconstructive surgeon. The two main options are: (1) latissimus dorsi musculocutaneous flap (LD-MC); or (2) its “modification”, the thoracodorsal artery perforator flap (TDAP). Both techniques have their advantages and disadvantages. The benefits of the TDAP flap include total preservation of the latissimus dorsi muscle,…

Partial breast reconstruction using reduction and mastopexy techniques

Synopsis ■ Breast-conserving therapy increases in popularity, driven by equivalent survival rates, preservation of body image, quality of life, and reduced physiologic morbidity. ■ Poor cosmetic results following breast-conserving therapy are not uncommon and are usually due to breast shape, tumor size, tumor location, and postoperative radiation. ■ Partial breast reconstruction is indicated whenever the potential for a poor cosmetic result exists, or for patients with…

Introduction to oncoplastic breast surgery

Access video and video lecture content for this chapter online at Elsevier eBooks+ Introduction Oncoplastic surgery continues to evolve as a viable option for women with breast cancer who desire partial mastectomy. Oncoplastic surgery is defined as wide excision of a local tumor using oncologic principles followed by the immediate or staged-immediate correction of the defect using plastic surgical techniques. The feasibility, safety, and efficacy of…

Secondary procedures following autologous reconstruction

Access video lecture content for this chapter online at Elsevier eBooks+ Introduction Breast reconstruction with autologous tissue transfer is an option for patients following unilateral or bilateral mastectomy. To date, approximately 26% of women in the UK undergo autologous reconstruction following mastectomy. The diversity of techniques available, each with its own indications and benefits, make it possible and essential to treat patients tailored to their individual…

Enhanced recovery after surgery (ERAS) protocols in breast surgery: techniques and outcomes

Access video content for this chapter online at Elsevier eBooks+ Introduction Perioperative pain management is an important aspect of any plastic surgery practice. As practitioners involved in invasive surgical procedures, plastic surgeons are intimately familiar with acute postoperative pain, chronic pain, and how pain affects our patients, both in the short term and long term. Uncontrolled pain can negatively affect postoperative patient outcomes and a patients’…

Management of complications following autologous breast reconstruction

Introduction Autologous breast reconstruction offers many advantages over alloplastic techniques and has become the procedure of choice for many women and surgeons. Transfer of well vascularized skin and fat allows for the creation of a long-lasting, aesthetically pleasing breast mound that feels and looks natural, without the need for foreign material. This is possible with success rates of 98%–99.5%. While the abdomen remains the most popular…

Stacked and conjoined flaps

Access video lecture content for this chapter online at Elsevier eBooks+ Introduction When available tissue from a single donor area is inadequate to achieve an aesthetically balanced result, stacked or conjoined multi-pedicle flaps from a single or multiple donor area(s) can provide a fully autologous-only breast reconstruction. In unilateral cases, the most common option is the stacked or conjoined bipedicled deep inferior epigastric perforator (DIEP) flap…

Innervation of autologous flaps

Introduction Post-mastectomy autologous breast reconstruction has evolved significantly since Tanzini described the first latissimus dorsi flap in 1906. The evolution has encompassed both limiting donor site morbidity as well as improvement in flap survival. While the focus of breast reconstruction up to this point has been on breast aesthetics, the next frontier aims to incorporate sensation. The goal of neurotization of autologous breast reconstruction flaps is…

Hybrid breast reconstruction: combining flaps and implants

Introduction Over 260,000 new cases of breast cancer are diagnosed annually in the US. Since the first report of implant-based breast reconstruction five decades ago, tremendous advances have been made in regard to surgical approaches to postmastectomy reconstruction. These advances have been paralleled by a substantial improvement of clinical outcomes, thus cementing the central role of breast reconstruction in breast cancer care. Advances in breast cancer…

Autologous reconstruction with the lumbar artery perforator (LAP) free flap

Access video lecture content for this chapter online at Elsevier eBooks+ Introduction The ideal breast reconstruction gives the patient a durable result that is aesthetically pleasing while causing minimal donor site morbidity. The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard, but when a DIEAP flap is not possible we should be able to provide an alternative to those patients seeking an autologous…