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Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Back

Introduction Reconstruction of the torso is a broad topic, which in and of itself includes techniques of local tissue rearrangement, skin grafting, local and regional flaps, as well as complex microsurgical reconstruction. The defects to be reconstructed are equally diverse and can include breast reconstruction, wounds related to spinal surgery, cardiothoracic surgery, abdominal wall reconstruction, or inguinal vessel exposure. The majority of these techniques are addressed…

Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection

Introduction Head and neck reconstruction presents unique challenges to the reconstructive surgeon. Because of the visibility of this region, defects are often difficult to conceal and the demands on the surgeon's reconstructive skills are greater than they are elsewhere in the body where cosmesis may be less vital and function less specialized. The head and neck area includes both static and dynamic structures and contains organs…

Robotic Applications in Plastic and Reconstructive Surgery

Introduction In recent years, robotic surgery has grown to dominate minimally invasive applications in the various surgical subspecialties. The currently available robotic surgical platform (da Vinci, Intuitive Surgical, Sunnyvale, CA) consists of two integrated subsystems: a surgeon console and a patient side cart ( Fig. 9.1 ). While seated at the console, the surgeon controls the instruments and endoscope using two small hand-operated mechanisms residing within…

Lymphedema: Microsurgical Reconstruction

Introduction Up until recently, lymphedema has largely remained on the sidelines of microsurgery. For many years, most microsurgeons avoided lymphatic reconstruction because of inconsistent results, lack of published data, and concerns regarding safety in a poorly understood disease process. Fortunately, the anecdotal era in lymphatic surgery is giving way to prospective studies and greater integration of our expanding knowledge of pathophysiology, imaging, and patient selection, into…

Percutaneous Aponeurotomy and Lipofilling (PALF): A Regenerative Alternative to the Flap

Introduction “Don't cut what you don't see!” This rule mandates large incisions and wide open surgical exposure to safely dissect aponeurotomic fibers and release restrictive scars or fascial structures. “Borrow from Peter to pay Paul.” This fundamental principle of flap reconstruction in plastic surgery creates defects at the donor site, generates more scars, creates wound healing issues, and often leads to reconstructions that look like patchwork.…

Tissue Engineering

Introduction Tissue engineering represents an interdisciplinary field, a forum where the principles of biomaterial engineering, the molecular biology of cells and genes, and the clinical sciences interact intensively through the combined efforts of scientists, engineers, and clinicians. Tissue engineering attempts to exploit the cells' reproductive potential and to harness the body's intrinsic capacity for healing and regeneration. These cells produce growth factors and cytokines, which function…

Prefabrication and Prelamination

Introduction Flap prefabrication and prelamination are distinct techniques designed to address complex reconstructive needs. While these techniques are generally not primary reconstructive options, their usage has increased in response to demands for more sophisticated reconstructive efforts. In reconstructive surgery, a delicate balance exists between the availability of matching donor tissue and the complexity of the recipient defect. Prefabrication and prelamination techniques have been applied to areas…

Emerging Technology in Reconstructive Surgery

Introduction In recent years, surgeons have taken advantage of various technologies to aid in microvascular free flap reconstructions. In this chapter, we discuss the use of virtual surgical planning and rapid prototype modeling for use in craniofacial reconstructions with vascularized bone flaps, which helps the surgeon to plan an idealized reconstruction with respect to restoring the facial skeleton and streamlines the creation of osteotomies. Indocyanine green…

Considerations in Flap Selection

Introduction A meticulous preoperative problem analysis leading to the selection of the proper strategy for solving the given wound, defect, or deformity can be a difficult task, yet certainly as critical as the actual surgical procedure that may be required. If a vascularized tissue transfer is indicated, there can then be little question that the selection of the correct flap is imperative as, if chosen improperly,…

Classification of Flaps

Introduction A Brief History of Flaps The history of plastic surgery is in many ways a recapitulation of the history and corresponding evolution of flaps ( Fig. 2.1 ). The earliest flaps were, as would be considered today, random skin flaps, as the skin was raised without regard to any known blood supply other than to maintain the presence of the subdermal vascular plexus. The classification…

Problem Analysis in Reconstructive Surgery: Reconstructive Ladders, Elevators, and Surgical Judgment

History of Reconstructive Surgery As one of my professors, the late Bradford Cannon, noted, the field of plastic surgery, unlike most other surgical specialties, has no anatomic or functional area to which it can lay claim; the plastic surgeon practices methods and techniques applicable to all specialties and anatomic areas. Plastic surgery as a specialty was based on, and continues to be defined by, the process…

Evidence-Based Medicine

Anesthesia in Patients With Traumatic Facial Injury ( Chapter 1.1 ) Clinical Question: What are the comparative benefits and harms of general and local anesthesia in patients with traumatic facial injury? Author Recommendation: In adults with acute facial trauma, in order to improve patient satisfaction and reduce pain and adverse effects, anesthesiologists, surgeons, and patients should participate in shared decision-making regarding selection of local or general…

Facial Transplantation

Background Facial Transplantation Experience The first facial transplantation was completed in France in 2005. Since that time, over 37 facial transplantations have been performed around the world. Of these cases, at least 28 have been the result of facial trauma. In fact, most of these cases have been performed secondary to ballistic injuries (n = 15), burn injuries (n = 8), or animal attacks (n =…

Secondary Nerve Reconstruction

Background Injury to the peripheral nerve branches of the craniofacial region can arise from a variety of surgical procedures. Common elective procedures such as dentoalveolar surgery, dental implant placement, endodontic treatment, orthognathic surgery, and facial esthetic surgery can result in injury to branches of the trigeminal nerve. Often overlooked in the evaluation of traumatic injury to the craniofacial skeleton or the surrounding soft tissue, is injury…

Posttraumatic Facial Pain

Background In order for a person to perceive facial pain, there must be a peripheral nerve pathway for neural impulses to travel from the site of injury into the central nervous system. The classic facial pain, “trigeminal neuralgia” or “tic doloureux” is not what this chapter is about, as that perceived pain originates within the central nervous system. Facial injury most often involves branches of the…

Virtual Surgical Planning

Background Since its emergence in the late 1980s, computer-assisted surgery (CAS) has become an increasingly important adjunct to craniofacial reconstruction. The refinement of virtual surgical planning (VSP) coupled with the availability of 3-dimensional (3D) printing techniques has enabled easier and more predictable remodeling of the craniofacial skeleton. As these techniques continue to develop, they point to a future in which ever more elaborate craniofacial challenges can…

Secondary Microvascular Reconstruction of the Traumatic Facial Injury

Background The preoperative planning and technical execution of craniofacial microsurgical reconstruction following traumatic injury is inherently complex. Patients may present with injury to any combination of tissue layers – including skin, vasculature, muscle, nerves, and bone – and reconstructive options span the entirety of the microsurgeon's armamentarium. These challenges are compounded in secondary reconstruction as prior reconstructive efforts may limit the surgical options available. Primary reconstruction…

Custom Craniofacial Implants

Background Craniofacial injuries are ideally treated in the acute setting. In certain circumstances, it is appropriate for treatment to be delayed. Resuscitation and treatment of life-threatening injuries in multiple trauma victims may preclude facial trauma treatment. For example, the treatment for patients with intracranial hemorrhage involves removal of portions of the skull for surgical access. The resulting brain and dural injuries are addressed acutely, but the…

Maxillofacial Prosthodontics

Background The replacement of missing structures in the head and neck region has been a concern for many centuries, with the fabrication of maxillofacial prosthetic restorations being mentioned since the 16th century, with the first mention often credited to Ambroise Paré in 1541. Although the concern was often the restoration of a pleasing appearance, addressing the functional disruption was also part of the treatment, with clinicians…

Secondary Traumatic TMJ Reconstruction

Background The temporomandibular joint (TMJ) is a complex and unique joint unlike any other joint in the body, with both translational and rotational function, and repetitive complex movement patterns to accommodate the functions of speech, mastication, and swallowing. For these reasons, posttraumatic secondary reconstruction of this joint remains a challenging prospect for treating clinicians, and as TMJ reconstruction is performed far less commonly than other joints…