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Scalp Reconstruction

Synopsis Scalp defects arise from a variety of etiologies and often have complex presentations. The reconstructive process begins with a thorough defect analysis, including size, location, wound conditions, and possible exposure of underlying structures. Reconstructive options follow the tenets of the reconstructive elevator, though the hair-bearing nature and inelasticity of the galea pose unique challenges for scalp reconstruction. Small defects may be amenable to primary closure…

Alveolar Bone Grafting

Synopsis Cleft lip and palate provides a four-dimensional reconstructive challenge, encompassing all tissue types and extending across the age spectrum from infancy into adulthood. This chapter focuses on alveolar bone grafting, a component of cleft reconstruction typically performed in early adolescence. The goals of alveolar bone grafting are to establish a solid bony foundation for the erupting adult dentition, to stabilize the maxilla into a single…

Primary Cleft Palate Repair

Synopsis A cleft palate represents a developmental failure in separating the oral and the nasal cavities. The communication allows for uncontrolled passage of air, liquid, and food between the two cavities, thus significantly impairing feeding and normal speech development. Anatomically, the levator veli palatine (LVP) muscular sling is disrupted, which is characterized by an aberrant orientation and insertion of the LVP onto the posterior edge of…

Secondary Cleft Lip Reconstruction

Synopsis Primary cleft lips are congenital and result from a failure of the medial nasal prominence of the frontonasal process to join with the maxillary process during embryogenesis. Variability in primary cleft lip defects consists of a spectrum based on their severity, such as complete/incomplete, the width of the cleft, and the alignment of the medial and lateral segments. In primary cleft lips, multiple surgical techniques…

Primary Bilateral Cleft Lip Repair

Synopsis Repair of a bilateral cleft lip deformity is challenging yet rewarding. Many surgeons find it hard to achieve results comparable to those of unilateral repairs. Poorly planned surgeries can leave noticeable residual deformities. There is a combination of genetic and environmental factors that may affect development of cleft lip in weeks 4 to 10 of gestation. These patients present along a spectrum of severity. Wide…

Primary Unilateral Cleft Lip Repair

Synopsis Caring for the unilateral cleft lip patient extends far beyond primary cleft lip repair. The complex needs of the cleft patient and family evolve as the child ages; therefore, a longitudinal multidisciplinary team approach is obligatory for proper care. In this chapter we present our preferred technique for repair of the unilateral complete and incomplete cleft lip deformity. Clinical Problem Unilateral cleft lip is the…

Common Free Flaps

Synopsis Free tissue transfer (“free flap”) reconstruction is commonly used to address defects of the body after trauma or tumor resection. A wide variety of tissue flaps exist, and flap selection should be based on requirements for coverage at the recipient site. Flaps can be designed to include skin, fat, fascia, muscle, bone, tendon, nerve, and various combinations of these tissue types. Successful flap reconstruction relies…

Microsurgery Essentials

Synopsis Microsurgical techniques are performed with an operating microscope and specialized instruments. They are useful when a skin graft or local flap(s) cannot adequately achieve reconstruction and in replantation surgery or nerve repair. The goal of microsurgical procedures is to restore form and function that is lost as a result of trauma, cancer, or congenital deficiency. Although it can be more complex than conventional surgery, microsurgery…

Local Skin Flaps

Synopsis Local skin flaps are time-honored methods of soft tissue reconstruction and frequently represent the ideal mode of reconstruction because they permit defect coverage with skin of similar color, thickness, and texture. Successful reconstruction using local skin flaps, however, requires a profound understanding of cutaneous vascular anatomy, skin biomechanics, and tissue geometry. Pre-operative errors in flap choice and design can substantially mitigate the likelihood for a…

Bone Fixation

Synopsis Fractures are prevalent worldwide, regardless of the economic status of the country. In low-income or middle-income countries, fracture treatment may be lacking or suboptimal. Acute fractures and complications such as malunion and nonunion have serious consequences that often interfere with community participation and prevent productive work. Restoration of skeletal stability can be life-changing and can offer the patient an opportunity to seek gainful employment, earn…

Tendon Repair

Synopsis Tendons are connective tissues that connect muscle to bone. They are instrumental in transmitting forces generated by muscle to move bones and joints. Tendon injuries are relatively common throughout the world and can significantly affect hand function. Various methods for tendon repair have been described. The optimal approach for surgical repair depends on the location of injury and type of tendon involved. Post-operative rehabilitation is…

Nerve Repair

Synopsis Nerve injuries can occur anywhere in the body. Reconstructive surgeons most commonly encounter them in the extremities or on the face. The management of nerve injuries requires a methodical pre-operative examination. Adjunct studies such as electrodiagnostic tests can be very helpful in confirming the diagnosis. The most important components of successful nerve repair are the debridement of injured fascicles, coaptation with no tension at the…

Skin Grafting

Synopsis Although the field of plastic surgery has advanced significantly in its ability to provide “like for like” coverage of wounds with various flaps, skin grafting still provides a facile, effective, and expeditious method of wound coverage. In the appropriate patient and with the proper technique, complications are minimal. The greatest limitations to skin grafting include donor site pain and appearance, need for specialized equipment, and…

Post-Operative Anesthetic Complications

Synopsis After successful surgery, the patient enters one of the most potentially hazardous phases of the procedure, namely emergence from anesthesia and the immediate post-operative period. The care team is busy with many tasks at this point, but the main attention should always be on the awakening patient and his or her needs. This chapter will focus on complications that may arise at that time, together…

Post-Operative Pain Control

Synopsis Adequate post-operative pain control minimizes suffering, improves patient satisfaction, promotes early mobilization, reduces the length of stay, and minimizes costs. Optimal pain control requires pre-operative education and perioperative pain management planning that encompasses a preventative analgesic approach that utilizes multimodal therapies such as systemic analgesia, local anesthetic infiltration, peripheral regional anesthesia, neuraxial analgesia, and cognitive-behavioral modalities. These principles can and should be applied for reconstructive…

PACU Setup and Requirements

Synopsis Delivering care to a post-operative patient in a developing country, with different practice environments than we are used to, can provide unique challenges. A post-anesthesia care unit (PACU), staffed by specially trained and educated nurses, is well recognized as crucial in optimizing patient outcomes. A PACU is commonplace in most of the developed countries in the world today, but that is not always the case…

Intraoperative Emergencies

Synopsis Intraoperative anesthesia emergencies are common. Many emergencies can be prevented by effective preoperative evaluation. Successful treatment requires adequate preparation of equipment and drugs. Routine simulation of emergency scenarios will increase the likelihood that the intervention will be timely and successful. The purpose of this chapter is to describe the prevention and treatment of these emergencies if they occur. Preparation Many emergencies can be prevented by…

WHO Safety Protocols and Process Excellence

Synopsis Surgery requires orchestration of numerous components, including requirements for satisfactory operating space; a clean, safe environment; working sterile equipment; and qualified anesthesia, nursing, and theater personnel. Also essential are factors outside of direct perioperative control. Guaranteeing that all of these pieces come together in the correct sequence, with the right timing, for every case is difficult under the best of circumstances. In austere operating environments,…

Regional Anesthesia

Synopsis The use of ultrasound (US) has revolutionized regional anesthesia and become an important component of surgical anesthesia and acute pain management. Its relative safety and ease of performance make it a perfect option for surgeries in resource-poor settings. Specifically, regional anesthesia is used to desensitize a precise body part to painful stimulus. Research suggests that acute post-operative pain continues to be undertreated. US-guided regional anesthesia…