Figure 109-8. A: Standard nipple-areolar complex tattooing after nipple reconstruction. B: 3D tattooing of nipple-areolar complex

without nipple reconstruction.

Although a variety of approaches have been described for breast reduction, common surgical options

share a number of characteristics. Most techniques of breast reduction resect both breast parenchyma

and redundant skin. Also, reduction procedures generally reposition the NAC to a more superior point

on the breast mound. To maintain nipple viability and sensation, the NAC usually is mobilized as part of

a pedicle of breast parenchyma or dermis. Following dissection of the nipple pedicle and reduction of

the surrounding breast skin and parenchyma, the pedicle is transferred superiorly with its vascular and

neural supplies intact, while the remaining breast is reapproximated around the nipple pedicle.

In categorizing reduction mammoplasty techniques, surgical options often are described in terms of

the nipple pedicle design. For example, the most common approaches rely on an inferiorly or centrally

based dermal–parenchymal pedicle to maintain vascular and nerve supplies to the NAC (Figs. 109-9A to

C and 109-10A to C).49–51 In designing skin incisions, traditional methods of reduction often have

incorporated a modification of a pattern originally described by Wise.52 While allowing considerable

flexibility in resection of redundant breast skin, the modified Wise pattern produces an inverted T –

shaped scar, the inferior portion of which runs along the inframammary fold (IMF) (Fig. 109-11). In an

effort to eliminate the IMF scar, Lejour et al.53,54 have described a vertical scar reduction mammoplasty.

Prospective outcome analysis of women undergoing reduction mammoplasty indicate that this

surgical intervention produces considerable improvements in somatic pain and in functional status.55,56

However, patients and providers also should be aware of the potential risks associated with reduction.

Complications reported with these procedures include instances of nipple or skin loss, changes in levels

of nipple sensation, hypertrophic scarring or keloid formation, contour deformities, and breast

asymmetry.

Figure 109-9. Inferior pedicle technique for reduction mammaplasty.

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Figure 109-10. Central pedicle technique for reduction mammaplasty.

Figure 109-11. Inferior pedicle Wise pattern bilateral breast reduction. A: Pre-operative. B: Post-operative.

Aesthetic Breast Surgery

Breast Augmentation (Augmentation Mammoplasty)

Augmentation or breast enlargement is one of the most commonly performed aesthetic procedures.

Evaluation of patients seeking breast augmentation should follow the guidelines described earlier.

Particular attention should be focused on thoroughly assessing several factors, including patient

preferences for postoperative breast size and shape, history of breast disease, and physical findings. The

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preoperative examination should evaluate and document any possible breast masses as well as existing

breast size, asymmetries, and contour deficits.

In planning augmentation mammoplasty, a variety of approaches and options are available. Decisions

regarding these choices are often best reached in consultation with the patient. Implants can be placed

through a variety of incisions including periareolar, IMF, and transaxillary approaches (Fig. 109-12).

With the advent of endoscopic techniques in recent years, transaxillary augmentation now can be

carried out with direct visualization of the implant pocket. This latter approach commonly produces

excellent aesthetic results with minimal visible skin scarring.

Location of the implant pocket is another critical decision in augmentation mammoplasty. Implants

can be placed anterior to the pectoralis major muscle (“subglandular” location) or posterior to the

muscle (“subpectoral” location). Subglandular placement usually results in less postoperative pain, but a

submuscular implant location may produce lower rates of capsular contracture57 and may pose fewer

difficulties in obtaining subsequent mammograms.58

Several choices also exist in selection of implant types. Since the mid-1990s, many surgeons have

been relying on the use of implants with textured surfaces to reduce capsular contracture rates.

Although textured surfaces appear to lessen scar tissue contracture,59 some patients and surgeons assert

that, compared with the smooth-walled envelope, the thicker, less pliable textured envelope gives the

augmented breast a less natural appearance and feel. With the reintroduction of silicone gel–filled

implants in the United States, patients and providers also have a choice of implant fill materials.

Although gel implants may produce aesthetically superior results compared with saline implants in some

patients, diagnosis and surgical treatment of implant rupture may be more challenging with gel devices.

Further refinements in silicone gel materials have led to the recent introduction of highly cohesive gel

implants which have an anatomic shape and a reduced the risk for gel leakage in the event of rupture.

Indications for highly cohesive gel implant use and critical aspects of patient selection are currently

under investigation.

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Figure 109-12. Breast augmentation via inferior mammary fold (IMF) incisions. A: Pre-operative. B: Post-operative.

Figure 109-13. A: Mild ptosis. B: Moderate ptosis. C: Severe ptosis.

Whatever options are chosen for breast augmentation, surgeons should clearly communicate with

patients about the potential risks of these procedures. The most commonly reported complications

include implant rupture, capsular contracture, implant infection, contour deformities, and breast

asymmetries.60 Despite the potential for local complications, there currently is no substantial evidence

that silicone gel filler material or implant envelopes are associated with increased risk for systemic

disease. To date, concerns voiced in the early 1990s about adverse “health effects” of silicone breast

implants appear to be unfounded.61 However, over the past decade a few cases of anaplastic large cell

lymphoma (ALCL) in patients with breast implants have been reported with growing evidence of an

association.62–64 The form of ALCL found in patients with implants tends to be benign, often regressing

after implant and capsule removal without systemic therapy.63,64

Mastopexy

Mastopexy (or “breast lift”) describes a category of surgical procedures designed to address redundancy

or laxity of the breast’s skin envelope, a condition termed ptosis of the breast. Breast ptosis can be

classified as mild, moderate, or severe, depending on the location of the NAC relative to the IMF (Fig.

109-13). Ptosis occurs when an imbalance exists between the volume of breast parenchyma and the

quantity of overlying skin. Mastopexy procedures usually reduce ptosis by removing redundant breast

skin and by relocating the NAC to a more superior position. These goals can be achieved through a

variety of skin incisions and excisions, many of which closely resemble techniques described earlier for

reduction mammoplasty. Fundamentally, mastopexy differs from breast reduction in that mastopexy

removes redundant skin while leaving most or all of the breast parenchyma. Approaches to mastopexy

range from minimal periareolar techniques to more extensive skin resections using more extensive

vertical incisions (Fig. 109-14A and B). As always, patients considering this procedure must weigh the

potential benefits of mastopexy (most notably, diminished ptosis) with the disadvantages (scars and

risks of complications) associated with the operation. Although relatively rare, the potential

complications of mastopexy closely parallel those described for reduction mammoplasty.

RECONSTRUCTIVE SURGERY OF THE HAND

Advances in plastic surgery have improved our ability to reconstruct hands that have been mutilated by

trauma, destroyed by arthritic diseases, or impaired by congenital conditions. Innovations in

microvascular techniques, wound management, and rigid fracture fixation have expanded the

capabilities of plastic surgeons by allowing them to borrow tissues from other parts of the body and use

them to reconstruct complex defects in the upper extremity in a single procedure. These innovations

provide limitless technical possibilities for the restoration of hand function and the eventual return of

patients as productive members of society. The following sections highlight the technical aspects of

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hand reconstruction and discuss indications for and applications of these techniques.

Trauma

Replantation

3 Since the first successful finger replantation by Komatsu and Tamai65 in 1968, replantation surgery

has flourished throughout the world. Thirty years of experience with replantation surgery has improved

our understanding of this procedure and has resulted in the development of indication guidelines to

ensure that replanted upper extremity parts not only survive, but have acceptable function as well. The

absolute indications for replantation (i.e., situations in which replantation should always be attempted)

are (a) thumb amputation, (b) multiple finger amputations, (c) pediatric population amputations, and

(d) mid-hand, wrist, or distal forearm amputations. The absolute contraindications for replantation are

(a) associated life-threatening injuries, (b) multiple-level injury in the amputated part, causing injuries

along the vessels and preventing blood flow into the replanted part, and (c) severe contamination of the

part, which carries a high probability of systemic infection if replanted. There are other situations in

which the benefit of replantation is debatable because outcome data are not available. For example,

single-finger amputation at zone II (a tight fibroosseous tunnel extending from the insertion of the

superficialis tendon at the middle phalange to the first annular pulley) is generally not recommended.

Tendon adhesion after zone II replantation may result in a stiff finger, which can interfere with the

overall performance of the hand. On the other hand, single-finger amputation at zone I (distal to the

superficialis insertion) is often recommended (Fig. 109-15). A stiff distal interphalangeal joint generally

does not cause much impairment, and nerve regeneration to the replanted part is quite rapid because of

the short distance to the terminal sensory organs. Furthermore, the aesthetic appearance of zone I

replantation is far superior to that of an amputation stump. In the future, the use of patient-related

outcome instruments and an increased body of replantation experience among centers will help to

define the utility of various digit replantation procedures.

Figure 109-14. Mastopexy procedures. A: Circumareolar technique. B: Vertical scar technique.

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Figure 109-15. A: Amputation of the index finger at zone 1 in a mechanic. The patient requested replantation because his work

requires fine manipulative tasks. B: Successful replantation with good aesthetic outcome and function.

Toe Transfer

When finger replantation is not possible or not successful, patients are left with significant functional

loss. Disability is most severe when the thumb has been amputated at or proximal to the

metacarpophalangeal joint or when all of the fingers have been amputated in machine injuries. In these

cases, toe transfer to the hand is an effective procedure in restoring grasp and pinch function. Although

a prosthesis is available to mimic the thumb, lack of sensation is a major drawback and often leads to

disuse of the prosthesis. For a patient who has had a thumb amputation at or proximal to the

metacarpophalangeal joint, big toe or second toe transfer to the thumb can create a sensate digit that

will oppose to the other fingers. Big toe transfer is advantageous because it provides a broad contact

surface and closely resembles the shape of the thumb, particularly when the big toe is trimmed and

sculptured to match the size of the thumb. However, the disadvantage of the big toe transfer is the

conspicuous donor site appearance in the foot and potential gait problems with foot push-off if the head

of the first metatarsal is taken along with the big toe. For these reasons, the second toe has become the

preferred method of transfer in some centers (Fig. 109-16). The disadvantage of the second toe transfer

procedure is the slender appearance of the digit as compared to the original thumb, but the donor site

appearance is quite acceptable. A recent outcome study, using objective physical measurements and

validated outcome questionnaires, demonstrated that toe-to-thumb transfer is an effective procedure in

restoring hand function.66 In addition, patients did not complain of gait difficulty after either big toe or

second toe transfer.

One of the most complex problems in hand surgery is the reconstruction of a hand without digits. To

create a new hand capable of tripod pinch, plastic surgeons can transfer multiple toes from both feet to

the hand (Fig. 109-17). This type of reconstruction can restore function to an otherwise useless hand

and has allowed two farmers who were treated at one center to return to heavy farm labor.

Complex Hand Injuries

Although crush injuries to the hand are common, injuries associated with sufficient force to disrupt the

structural integrity of the wrist and to sever the blood supply to the hand are uncommon events (Fig.

109-18). Because multiple structures are traumatized in injuries of this kind, a systematic treatment

approach is important in salvaging the hand and in restoring its function. Crucial steps in the

management of this injury are: (a) ruling out other injuries, (b) aggressive débridement, (c) skeletal

fixation, (d) decompression of fascial compartments in the hand, (e) revascularization, (f) tendon repair,

(g) nerve repair, and (h) early soft tissue coverage (within 1 week of injury).

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Figure 109-16. A: Second-toe transfer for thumb reconstruction in a carpenter. He sustained a thumb amputation at the

metacarpophalangeal joint while using a saw at work. B: Good function with restoration of fine pinch. The patient returned to

work as a carpenter 3 months after the toe reconstruction.

Figure 109-17. A: A farmer who lost all his fingers when he was injured by a corn picker. A groin skin flap was used to cover the

exposed metacarpal heads. B: A second toe was removed from one foot to reconstruct the thumb, and the second and third toes

were removed together from the other foot to reconstruct the fingers. Note the good opposition of the thumb and acceptable

flexion of the digits. The patient returned to work on his dairy farm after the hand reconstruction.

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Figure 109-18. A: Accidental shotgun blast injury in a 16-year-old boy. Both the radial and ulnar arteries were ruptured, and the

hand was ischemic. The wrist was destroyed, and multiple tendons and nerves were severed. B: Volar wrist wound. Markings show

incision lines for ulnar artery exposure.

Ruling Out Other Injuries

In devastating trauma, attention is often focused on the obvious injury, and injuries to other organ

systems may be ignored. In a review of 1,100 patients referred for emergent microsurgery over a 7-year

period, investigators found 9 cases (0.8%) of unrecognized life-threatening injuries that required

abandonment of the microsurgical procedures.67 Therefore, systematic trauma evaluation and ruling out

other associated injuries should precede treatment of the hand injury.

Débridement

Severe crush and blast injuries are associated with large zones of injury, and the wounds may be

contaminated with foreign materials such as grease or paint, as in printing-press injuries. In these cases,

aggressive débridement is important in preventing infection. Except for critical structures that include

nerves and tendons, all devitalized soft tissues and bone fragments must be excised. The concept of

radical débridement has been shown to decrease wound infection and improve success of microvascular

reconstruction.68

Skeletal Fixation

After débridement, the next priority is to stabilize the wrist and to rigidly fix hand fractures. A stable

wrist provides a platform for repairing other injured structures. If the crush injury is associated with

comminuted fractures of multiple carpal bones and rupture of the intercarpal ligaments, wrist fusion

may be the best option because it is often impossible to reconstitute the normal anatomy of the distal

and proximal carpal rows in face of severe comminution of the carpal bones. To avoid possible bone

graft contamination with primary wrist fusion, external fixators are placed for provisional fixation

during the initial débridement. Definitive wrist fusion with bone grafting is performed after adequate

débridements and during the flap coverage procedure. Two 2.7-mm fixator pins are placed through an

incision along the radial index metacarpal, and two proximal 3.5-mm pins are placed into the radius

using an incision along the radial border of the distal radius, between the brachioradialis and the

extensor carpi radialis longus. The superficial radial nerve, which lies under the brachioradialis, is

dissected free and retracted away from the pins. External fixator rods are then secured to the pins with

nuts and screws. If the wound is clean during the second-look procedure at 24 or 48 hours, total wrist

fusion is then undertaken (Fig. 109-19). Otherwise, the external fixator is left in place until the wound

is suitable for fusion using internal plating and cancellous bone grafts. This stable skeletal fixation

allows early hand therapy, usually instituted on postinjury day 7 when tissue edema is subsiding.

Revascularization

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In a crush injury of the wrist, the zone of injury can be extensive. Use of vein grafts is essential in

performing the arterial anastomosis away from the zone of injury. The ulnar artery is chosen for repair

because it is the dominant artery in most patients and because it can be exposed readily in the

hypothenar area. If the ulnar artery is contused in the palm, distal anastomosis can be performed to the

superficial palmar arch. Because soft tissue bridges are often present, venous outflow is not a problem

and venous anastomosis is not necessary.

Decompression of Fascial Compartments

Increased edema associated with crush injuries often raises the compartmental pressures in the intrinsic

muscle compartments and in the carpal tunnel. Prior reviews have shown a high incidence of ischemia

and resultant fibrosis of the intrinsic muscles following crushing trauma to the hand.69 Consequently,

surgeons perform prophylactic carpal tunnel releases and intrinsic muscle decompressions in severe

crush injuries of this kind.

Figure 109-19. A, B: Note destruction of the wrist joint, in addition to comminuted fractures of the distal ulna and radius. C: Total

wrist fusion was performed 48 hours after the initial injury.

Soft Tissue Coverage

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After aggressive débridement, a soft tissue defect is often present around the wrist. A split-thickness

autograft is placed over the vein graft to prevent desiccation. Other open wounds can be covered

temporarily with homografts. If wrist fusion is undertaken during the second-look procedure, primary

wound closure can be achieved. For residual wound defects, split-thickness autografts are used to cover

the exposed muscle bellies. However, if tendons or nerves are exposed, coverage with either

fasciocutaneous or muscle free flaps will allow earlier tendon mobilization and prevent tendon

adhesions. Definitive early wound coverage is important in protecting vital structures and avoiding

wound colonization with bacteria (Fig. 109-20).

Nerve Repair

When nerves are crushed, the delineation between viable and nonviable nerve fascicles is difficult to

assess in the acute setting. Therefore, the traditional approach is to delay the nerve grafting procedures

until 2 or 3 months after injury. To prevent retraction of the nerve ends, we suture the nerve ends to

the surrounding soft tissues. However, secondary nerve grafting is often difficult because of the amount

of scar in the wound. One way is to primarily graft the nerve injury at the expense of more aggressive

resection of the traumatized nerve ends.

Figure 109-20. A: A free rectus muscle was used for immediate coverage of the reconstructed wrist and tendons. B: The hand was

salvaged, and the patient has acceptable hand function after secondary nerve and tendon reconstruction.

4 In conclusion, rigid skeletal fixation, revascularization using vein grafts, and immediate wound

coverage are crucial factors in successful limb salvage.

Congenital Anomalies

Syndactyly

Syndactyly is a condition in which the fingers are fused. It can be classified as complete or incomplete.

Complete syndactyly is the union of the digits extending to the distal phalanx. Incomplete syndactyly is

the union of the digits proximal to the distal phalanx but distal to the normal webbing at the

midproximal phalanx. Syndactyly is further categorized as simple or complex. In simple syndactyly,

there is no bony union between the digits, whereas complex syndactyly includes bony union.

Typically, syndactyly can be separated when the child is 1 year of age. Surgery should be performed

earlier if syndactyly affects the thumb–index finger or ring–little finger web space and causes deviation

of the shorter digits during growth. Separating the fingers requires meticulous design of the skin flaps,

and the dorsal skin flap is most crucial to creating a web space that is not prone to contracture (Fig.

109-21). Distally, triangular skin flaps are designed to drape the sides of the fingers. A full-thickness

skin graft from the groin is often required to cover open areas in the fingers.

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Figure 109-21. A: A simple, complete syndactyly in a 1-year-old child. Note the design of the dorsal skin flap to reconstruct the

web space and the interdigitating distal skin flaps. B: Immediate postoperative photograph of the syndactyly release.

Figure 109-22. A: Wassel type 3 thumb duplication in a 2-year-old child. B: The radial digit was hypoplastic and was removed. C:

Intraoperative picture shows the aesthetically pleasing reconstructed thumb.

Thumb Duplication

Although thumb duplication does not often cause a functional problem for the child, the presence of this

prominent hand malformation can have a significant impact on the child’s psychosocial development.

Surgery can be undertaken when the child is about 2 years old to prevent progressive deviation of the

thumb during growth. Thumb duplication can be classified into seven groups, depending on the level of

the duplication. Type I consists of a bifid distal phalanx, whereas type II is a complete duplication of the

distal phalanx. Types III and IV involve the proximal phalanx, and types V and VI involve the

metacarpal. Type VII is triphalangeal thumb or a thumb with three phalanges. Usually the radial, less

developed thumb is removed. Retention of the ulnar thumb has the added advantage of preserving the

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