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Reconstructive surgery: lower extremity coverage

Access video and video lecture content for this chapter online at Elsevier eBooks+ Introduction Lower extremity reconstruction following severe trauma, cancer ablation, and chronic infections remains challenging. The involvement of multiple structures from bone, muscle, vessel, nerve to skin makes it difficult to achieve the goals of lower extremity reconstruction where restoration of limb function, coverage for vital structures, and satisfactory appearance is achieved. In recent…

Lower extremity sarcoma reconstruction

SYNOPSIS Any lesion in the lower extremity with a clinical history of pain, continuous growth, size over 5 cm, or deep subfascial localization is suspicious of a sarcomatous malignancy and should be surgically biopsied according to established surgical rules. Still the single statistically proven modality of curing sarcomas and prolonging postsurgical lifespan is surgical excision with wide margins resulting in a postoperative R 0 -status. To…

Debulking strategies and procedures: excision

Access video and video lecture content for this chapter online at Elsevier eBooks+ Chen-modified Charles procedure In advanced lymphedema, chronic inflammation and repeated episodes of infection lead to gradual fibrosis of subcutaneous tissue and skin, causing destruction of lymphatic channels, and it is not suitable for microsurgical lymphovenous anastomosis. The most important goal of treatment for lymphedema is control or eradication of infection. In particular, prevention…

Debulking strategies and procedures: liposuction of leg lymphedema

Access video content for this chapter online at Elsevier eBooks+ Introduction Our first liposuction was undertaken in 1987, but it was not until 1993 that a more detailed treatment protocol was established for arm lymphedema. Liposuction for leg lymphedema was established 5 years later. Initially the “dry” technique was used. The introduction of use of a tourniquet and tumescence has made liposuction a safe procedure, and…

Vascularized lymph node transplant

Access video and video lecture content for this chapter online at Elsevier eBooks+ History of VLNT Vascularized lymph node transplant (VLNT) is one type of physiologic surgical treatment for lymphedema that has been shown to be effective in reducing affected limb girth and decreasing reliance on decongestive therapy for patients with upper and lower extremity lymphedema. It has been employed for both primary, or congenital, lymphedema,…

Lymphaticovenular bypass

Access video and video lecture content for this chapter online at Elsevier eBooks+ Introduction Historically, the treatment of lymphedema has been focused on ameliorating symptoms and halting the progression of disease. However, with recent advancements in reconstructive microsurgery and supermicrosurgery, lymphedema is now a surgically manageable condition. Operative management of lymphedema can be categorized according to the guiding principles of each operation. Debulking procedures such as…

Imaging modalities for diagnosis and treatment of lymphedema

Access video content for this chapter online at Elsevier eBooks+ Introduction The development of microsurgical instruments and surgical methods has led to an advanced curative lymphedema treatment. Reductive procedures (direct excision, liposuction) and physiologic reconstructive methods, such as lymphovenous anastomosis (LVA), vascularized lymph node, vessel or system transfer (VLNT, VLVT, LYST), and lymph node–venous anastomosis (LNVA) are now available. As the therapeutic palette broadened, there has…

Management of lower extremity trauma

Synopsis ■ Lower extremity trauma is commonly associated with other organ injuries. ■ A primary survey is essential to quickly recognize life-threatening conditions and perform critical interventions as early as possible. ■ The initial assessment of extremity trauma involves evaluating vessel, bone, nerve, and soft-tissue injury, and checking for compartment syndrome. ■ A multidisciplinary approach with an orthoplastic concept is applied from diagnosis to rehabilitation. ■…

Secondary facial reconstruction

Synopsis ■ The goals of secondary facial reconstruction span from simply closing a wound to restoring facial function while achieving as close to a normal appearance as possible both in repose and during animation. ■ To reconstruct a missing part, the “best” option should be employed, and the sequential thought process of a “reconstructive ladder” should be discarded for a “reconstructive elevator” to find the appropriate…

Comprehensive lower extremity anatomy

Synopsis ■ Success in lower extremity reconstruction is dependent on a comprehensive understanding of structural and functional anatomy. An anatomic- and defect-specific approach to lower extremity reconstruction enables the surgeon to provide tailored solutions for both the preservation and restoration of a functional limb. ■ A comprehensive appreciation for normal lower extremity anatomy and anatomical variants is critical to functional limb salvage when treating lower extremity…

Oral cavity, tongue, and mandibular reconstructions

Synopsis ■ In head and neck reconstruction, a comprehensive assessment of the patient’s disease status, defects of the oral cavity, tongue, and mandible are critical to achieving optimal functional results with minimal complications. ■ Thorough evaluation of the defect includes its size, shape, geometry, and relationship to the adjacent structures. ■ A strategic approach to flap selection of soft-tissue flap or osseous flap should accurately reconstruct…

Lip reconstruction

Synopsis ■ While normal appearance of the lip is ideal, the primary objective of lip reconstruction is the restoration of a functional oral sphincter with adequate aperture for proper feeding and speech. ■ Etiology, size, and missing components of the lip defect must be assessed. ■ Vermilion defects should preserve the vermilion border whenever possible. ■ Partial-thickness defects involving less than a quarter of the upper…

Local flaps for facial coverage

Synopsis ■ The differences in skin texture and laxity with age must be considered when choosing a local flap for facial coverage. ■ The plastic surgeon’s goal is not to cover a facial wound, but instead to reconstruct the characteristics of the missing tissue. ■ Survival of random flaps depends on perfusion pressure and on intravascular resistance of the region of skin being used and not…

Post-oncologic midface reconstruction: the Memorial Sloan-Kettering Cancer Center and MD Anderson Cancer Center approaches

Synopsis ■ The maxilla may be thought of as a six-walled geometric box. ■ Most extensive midface defects require free flaps for reconstruction. ■ Complex structures such as nose, eyelids, and lips should be reconstructed separately, usually with local flaps. ■ Understanding the defect, especially the bony structure and soft-­tissue elements that need to be restored, is key to successful midfacial reconstruction. ■ The classification of…

Overview of head and neck soft-tissue and bony tumors

Synopsis ■ While cutaneous malignancies are the most common cancer of the head and neck region, the most common cancer arising from the mucosa is squamous cell carcinoma (HNSCC). ■ 5-year survival outcomes for head and neck cancer patients have improved across all ages and all sites, except the larynx, increasing from 55% to 66% from 1992 to 2006. ■ Once diagnosed, head and neck cancer…

Computerized surgical planning in head and neck reconstruction

Synopsis ■ This chapter will help illustrate the ease with which virtual surgery and computer-aided design and manufacturing can be used to create accurate postoperative results and provide confidence with complex three-dimensional bony injuries and reconstructions. ■ With advancements in software technology and three-dimensional printing, our ability to plan and execute precise bony reconstruction has become a reality. ■ With this technology, guides can be made…

Three-dimensional virtual planning in orthognathic surgery

Advances in three-dimensional (3D) imaging and modeling have significantly changed the practice of treatment planning in patients with congenital or developmental facial skeletal differences. With improvements in imaging technology, such as computed tomography (CT), cone beam computed tomography (CBCT), 3D photography, and 3D intraoral dental scanners, the ability of the clinician to evaluate and treat facial dysmorphology has been revolutionized. Furthermore, advances in 3D surgical planning…