important stabilizing ulnar collateral ligament. The surgery requires a delicate reconstruction of the

bone, ligament, and tendon structures to sculpture the remaining thumb as normally as possible (Fig.

109-22). After the immediate postsurgical period, these patients are followed once a year to evaluate

potential growth abnormality.

Hypoplasia and Aplasia of the Thumb

The thumb contributes about 50% of hand function and is important in pinch and grip. Reconstruction of

the underdeveloped thumb is critical in improving hand function for the child. Hypoplasia of the thumb

can be classified into five grades, and treatment options are often based on this classification. Grade I

consists of minor hypoplasia; all components of the thumb are present, but the thumb is smaller than

normal. Grade II consists of adduction contracture of the first web space and laxity of the ulnar

collateral ligament at the metacarpophalangeal joint; the thenar musculature is hypoplastic but the

skeletal framework of the thumb is normal. Grade III includes severe hypoplasia of the thumb with

absent intrinsic muscles and underdeveloped extrinsic tendons; the skeletal framework is hypoplastic

and the carpometacarpal joint is vestigial. Grade IV is characterized by a floating, nonfunctional thumb

(pouce flottant), with soft tissue attachment of the thumb at the metacarpophalangeal joint of the index

finger. Grade V is defined by total absence of the thumb. Grade I hypoplasia does not require treatment

and grades III, IV, and V require index pollicization (reconstructing a thumb using the index finger) for

optimal function (Fig. 109-23). In grade II, the thumb can be reconstructed by using a combination of

tendon, joint, and soft tissue procedures.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a crippling disease that severely affects the quality of life for millions of

Americans. RA is postulated to be an autoimmune disease mediated by inflammatory cells that attack

the synovial tissues in the body. Persistent synovitis in the joints causes erosion of the articular surfaces

and disrupts their soft tissue supports.

Because the hand is often damaged by RA, effective surgical treatment of hand deformities can

improve patient function and restore independence. The goals of surgery for the rheumatoid hand

include: (a) pain control, (b) improvement or restoration of function, (c) prevention of disease

progression, and (d) aesthetic improvement. To accomplish these goals, the surgeon must have good

rapport with both the rheumatologist and the patient as priorities of treatment are determined. By

listening to patients with RA describe their impairments and their goals, the surgeon can gain insight

into the surgical plan that will offer the patient the most benefit.

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Figure 109-23. A: Absence of a thumb in a 2-year-old child. Note the floating thumb attached to the index finger. B: Immediate

appearance in the operating room after pollicization. C: Three months after index pollicization, the child is able to use the new

thumb for grasp and fine pinch.

Surgical treatment can be classified as preventive, corrective, or salvage.70 Preventive procedures

include tenosynovectomy to avoid tendon rupture and synovectomy to ameliorate ongoing joint

destruction from erosive synovitis in the joints. Corrective procedures include tendon transfers for

tendon ruptures and nerve decompression for carpal tunnel syndrome. Salvage procedures consist of

joint arthroplasty and joint fusion.

A common hand deformity in RA consists of subluxation and ulnar deviation of the fingers at the level

of the metacarpophalangeal joints (MPJs) (Fig. 109-24). Synovitis at the MPJs distends the joints and

attenuates the supporting ligaments. Wrist destruction in RA contributes to the radial deviation of the

metacarpals, which accentuates the ulnar deviation of the fingers. With progressive MPJ disease,

patients have great difficulty opening their hands because of subluxation of the MPJs and difficulty with

fine pinch because of the ulnar deviation of the fingers. In addition to pain at the MPJs secondary to

their worn articular surfaces, RA patients often complain of the aesthetic appearance of their hands.

The Swanson metacarpophalangeal joint arthroplasty (SMPA) is an effective procedure that will meet

all four goals of RA surgery. By replacing the arthritic joints with prosthetic spacers and realigning the

soft tissue envelope around the MPJs, surgeons are able to markedly improve function and enhance the

aesthetic appearance of RA hands. A recent systematic overview of the world’s literature on this

procedure showed that SMPA is an effective procedure in improving the health-related quality of life for

RA patients.71

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Figure 109-24. Severe destruction of the metacarpophalangeal joints with ulnar deviation of the fingers of the left hand. Note

restoration of normal finger alignment of the right hand after Swanson metacarpophalangeal joint arthroplasty.

AESTHETIC SURGERY

Plastic and reconstructive surgery is a discipline that adapts broad surgical principles to a multitude of

unique clinical problems by altering form and function. Plastic surgery not only restores physical

function, it also enhances a patient’s body image and self-esteem. In no other area of surgery is this

truer than in aesthetic surgery. A blepharoplasty may not only improve the appearance of baggy, tired

eyes, but also may treat visual field defects caused by eyelid ptosis or blepharochalasis. A rhinoplasty

can improve the outward appearance of a nose as well as the nasal airflow and breathing.

5 Aesthetic surgery requires meticulous attention to detail, careful patient selection, rigorous

procedural planning, and precise execution of technically challenging procedures. If patients are

carefully selected and their goals are realistic, then the chances for a successful outcome are good.

However, if a patient is poorly selected or they have unrealistic goals, then a technically successful

operation with an aesthetically pleasing outcome may be a dismal failure in the eyes of the patient. The

aesthetic surgeon must not only diagnose the clinical deformity, but must also carefully evaluate the

patient’s expectations and motivations for surgery. Through the application of sound surgical principles

and technical expertise, the aesthetic surgeon can experience life-long career and personal satisfaction.

Cosmetic Procedures for the Head and Neck

Brow Lift

Brow ptosis is a natural consequence of the biologic process of aging. If left uncorrected, patients can

appear angry, tired, or older than their chronologic age. If severe, brow ptosis may cause visual field

obstruction on upward gaze; correction of this deformity can produce dramatic functional and aesthetic

improvements. Patients frequently present with the complaint of looking tired or angry and request a

blepharoplasty. In many cases, the etiology of their complaint is brow ptosis rather than upper eyelid

ptosis or blepharochalasis. These patients will require a brow lift alone, or in combination with a

blepharoplasty, to correct their functional and aesthetic concerns.

Correction of brow ptosis can be achieved with either an open or endoscopic approach. The

traditional open approach requires a transcoronal incision with resection of excess scalp or forehead.

Unfortunately, this approach results in a long scar, potential scar alopecia, and anesthesia of the scalp

and forehead. In addition, an open brow lift in male patients with a receding hairline requires resection

of hair-bearing scalp, which is an undesirable outcome. To reduce these complications, the endoscopic

brow lift was developed and has become the primary approach for repair of brow ptosis.54 The

endoscopic brow lift requires only three to five 1-cm incisions behind the hairline to gain access to the

forehead and glabellar rhytids, producing less of an aesthetic deformity and limiting the amount of

scarring. There is also evidence to suggest that the endoscopic approach produces a more lasting result

than the traditional approach.55 Finally, it has been reported that anesthesia of the forehead and scalp is

significantly reduced when an endoscopic approach is utilized for correction of brow ptosis, as

compared to an open, transcoronal approach.

Endoscopic and open brow lifts may be performed under local or general anesthesia. Patients are

marked preoperatively in the upright position. The desired brow position is at the level of the orbital

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rim in male patients and 1 cm above the orbital rim in female patients. The position of the brow in

relation to the supraorbital rim changes from medial to lateral; the lateral brow should be more

elevated than the medial brow. During an open brow lift, a coronal incision is made and the entire

forehead is mobilized in a subgaleal or subperiosteal plane down to the orbital rim. The supraorbital

and supratrochlear nerves are dissected free of surrounding tissues and preserved. The corrugator and

procerus muscles are resected if prominent glabellar rhytids are present. Excessive resection of the

corrugator muscles will result in widening of the eyebrows in the midline. The periosteum is released at

the level of the supraorbital rim when a subperiosteal plane is utilized for mobilization of the forehead;

the dissection is carried down to the level of the supraorbital rim when a subgaleal plane is used for

forehead mobilization. The forehead is then elevated and redraped posteriorly, the redundant scalp is

resected, and the wound is closed. In an endoscopic brow lift, incisions are made within the hair-bearing

scalp at the midpupillary line and over the temporal fossa. The entire forehead flap is elevated under

endoscopic guidance, the procerus and corrugator muscles are resected as necessary, and the forehead is

retracted posteriorly. The forehead is then secured into its new position. Various methods of forehead

fixation have been described including; absorbable and nonabsorbable plates, screws, mutlipronged

anchors, or cortical tunnels.71,72

Postoperatively, patients are instructed to avoid vigorous physical exercise for at least 6 weeks.

Bruising and swelling are anticipated for the first 2 to 3 weeks following the procedure. The final result

is not expected for at least 6 to 8 weeks following the procedure.

Rhytidectomy

The deleterious effects of aging, gravity, sun exposure, and smoking are particularly evident on the

face. Ultraviolet radiation and tobacco use produce fine facial wrinkling and skin laxity as a result of the

loss of skin elasticity. Aging and gravity result in gradual relaxation of the facial retaining ligaments

producing midfacial ptosis, deepened nasolabial folds, “jowling” along the mandibular border, and

redundancy of cervical skin.73 Old family photographs and driver license photographs are constant

reminders of a more youthful appearance with high cheekbones, a sharp mandibular border, and smooth

skin. However, as the aging process marches on, patients may lose self-confidence and self-esteem in

social, political, and business situations, encouraging them to seek facial rejuvenation surgery. If the

patients are selected appropriately and the surgery is carefully planned and executed, the results will be

gratifying for both patient and surgeon.74

During the preoperative evaluation, the patient’s expectations and motivations are carefully evaluated

and addressed. Surgeons need to be cautious of patients whose concerns about their appearance are out

of proportion to their physical deformity. Under these circumstances, a perfectly designed and

performed operation may still have a dismal outcome in the eyes of the patient.

6 Patients who smoke are at a significantly increased risk for developing postoperative complications,

including skin-flap necrosis, infection, or wound dehiscence, and are consequently instructed to quit

prior to undergoing elective aesthetic surgery. Many surgeons will refuse to perform a cervicofacial

rhytidectomy in any patient who is actively smoking or utilizing any products containing nicotine. Urine

cotinine levels can be determined to confirm whether a patient has been utilizing nicotine in any form.

Older patients with coexisting medical illnesses are referred to a general practitioner for optimization of

their medical condition preoperatively. If the patient is deemed a moderate or high risk for general

anesthesia because of medical comorbidities, then the operation may be postponed until those medical

conditions are optimized. Occasionally, if the risk of anesthesia is too high for a patient, then the

operation may need to be cancelled.

Younger patients (40 to 50 years old) with good skin quality, mild midfacial ptosis, and early

“jowling” may benefit from a minimally invasive facelift. This operation is typically combined with an

endoscopic brow lift to provide upper and lower facial rejuvenation with minimal scarring. The

operation is performed under local or general anesthesia. Bilateral temporal and superior buccal sulcus

incisions are made. The temporal fossa dissection is carried down to the level of the superficial layer of

the deep temporal fascia. Under endoscopic guidance, the superficial layer of the deep temporal fascia is

then incised to expose the temporal fat pad. The dissection then proceeds caudally until the zygomatic

arch is identified. A subperiosteal plane of dissection provides access to the midface while preserving

the integrity of the frontal branch of the facial nerve. The subperiosteal plane of dissection is continued

into the midface with care taken to avoid the infraorbital nerves. The masseter is mobilized from its

lateral attachments. The superior buccal sulcus incisions are made, and a midface subperiosteal

dissection is performed under both direct visualization and endoscopic guidance. Once the dissection is

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completed, the entire midface is suspended in the desired position with sutures or specialized anchors

spanning from the superficial layer of the deep temporal fascia to the midface periosteum. Symmetry of

the suspension is then confirmed and the wounds are closed in layers. This technique will nicely correct

mild midface ptosis, mild jowling, and early nasolabial fold prominence. However, this technique will

not correct deformities from significant skin laxity. Under these circumstances, a traditional

cervicofacial rhytidectomy will be required.71,75

In patients who require resection of excess skin, a traditional rhytidectomy can be performed under

local or general anesthesia. The skin incision is made over the temporal fossa 4 to 5 cm cephalad to the

root of the helix and extended caudally toward the apex of the ear. The incision is then extended

anterior to the ear, behind the tragus, around the base of the earlobe into the retroauricular sulcus,

across the mastoid, and caudally along the anterior hairline of the neck. The skin flap is then elevated

just superficial to the superficial musculoaponeurotic system (SMAS) and platysma. This plane of

dissection maintains a thin layer of subcutaneous fat on the skin flap to preserve viability, while

avoiding injury to the facial nerve branches, greater auricular nerve, parotid gland, and jugular vein.

The flaps are elevated medially to the nasolabial fold in the face and to the midline in the neck.

Occasionally a platysmal diastasis may exist which creates platysmal banding, an obtuse cervicomental

angle, and a prominent neck. Under these circumstances, a platysmal plication may be performed

through a 2- to 3-cm submental incision to correct the diastasis and improve the appearance of the neck.

At this point, there are many variations in how the remainder of the cervicofacial rhytidectomy is

performed with the goal of repositioning all of the tissues which have migrated into dependent positions

creating facial aging changes. The surgeon may simply chose to not perform any additional dissection at

this point and simply reposition the skin, resect the excess skin, and close the incisions. In other

circumstances, the surgeon may choose to do one of the following; SMAS plication, standard SMAS

dissection, extended SMAS dissection, or deep-plane dissection. These operations are all designed to

improve control of facial and cervical tightening, while reducing the tension on the skin closure. Once

the dissection of the facial tissues is completed and all planes are mobilized optimally, the SMAS and

platysma are placed under tension and secured to create the desired facial appearance. The skin flaps

are then redraped posteriorly, the patient is examined for symmetry, and a skin resection is performed.

Hemostasis is obtained through judicious use of bipolar electrocautery. The wounds are closed in layers

and a pressure dressing is applied. Drains are typically used in the face and neck.76–80

Postoperatively, the patient is evaluated in the recovery room for any evidence of a hematoma or

facial nerve injury. It is crucial to identify a hematoma early to avoid overlying skin necrosis. Facial

nerve injuries occur in only 2% to 3% of cases. On the first postoperative day, the pressure dressings

and drains are removed and the patient is examined for evidence of a late hematoma, unrecognized

facial nerve injury, or compromised skin flap. Patients should expect to have significant swelling and

bruising for at least 2 weeks following the procedure. The final postoperative result is not realized until

approximately 6 months following the procedure (Fig. 109-25).

Blepharoplasty

Eyelid surgery may be performed to correct functional or aesthetic deformities. Excessive skin and fat

of the eyelids can give the patient an angry, aged, or tired look and may cause visual field obstruction.

Older patients typically present with redundant skin and fine wrinkling, whereas younger patients

commonly complain of persistent bags under their eyes or fine wrinkling (“crow’s feet”) at the lateral

canthus. Treatment of each clinical entity requires a unique approach based on the diagnosis and

presentation.81 All patients being evaluated for blepharoplasty require a complete ophthalmologic

examination preoperatively to evaluate visual acuity, upper eyelid ptosis, exophthalmos, lower eyelid

laxity, and symptoms of “dry” eye. Meticulous attention to details is critical for the successful outcome

of blepharoplasty surgery.72 If there is lower lid laxity preoperatively, and a standard blepharoplasty is

performed, the patient may develop a lower lid ectropion postoperatively. Symptoms of dry eye can

also be significantly worsened by a blepharoplasty. As a result it is critically important to perform a

comprehensive evaluation of the health of the eye prior to performing any eyelid surgery.

Once a complete evaluation has been performed and a diagnosis has been made an operative plan can

be formulated to correct the concerns of the patient. The operation can be performed under local or

general anesthesia. Older patients frequently require skin excisions and removal or repositioning of

orbital fat. The blepharoplasty incisions are designed preoperatively with the patient in the upright

position. Local anesthesia with epinephrine is then infiltrated for pain control and hemostasis. The upper

eyelid blepharoplasty then begins with an elliptical excision of upper eyelid skin and orbicularis oculi

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muscle. The skin excision is designed based on the amount and location of the blepharochalasis. Very

rarely will a patient require removal of fat from the upper eyelids. Excessive fat resections will produce

a “hollowed-out” appearance. However, occasionally there may be a substantial amount of excess

orbital fat in the upper eyelids and conservative fat resection may be helpful to achieve the desired

postoperative outcome. If a fat resection is going to be performed, small openings are made in the

orbital septum to gain access to the two compartments of periorbital fat. A conservative fat resection is

then performed to avoid a postoperative hollowed-out appearance. The skin is then redraped and the

wounds are closed in a single layer. If an upper lid blepharoplasty is being performed in conjunction

with a brow lift, the brow lift should be performed first, so that the amount of excess upper eyelid skin

can be determined after the brow has been elevated.

The traditional lower eyelid blepharoplasty begins with a subciliary incision. A 4- to 5-mm rim of

orbicularis oculi is then preserved along the lower eyelid margin. The dissection is then carried deep to

the orbicularis oculi muscle until the orbital septum is identified. The orbital septum is then divided to

gain access to the three compartments of periorbital fat in the lower lid. Fat may be resected in cases of

prominent herniation, but overresection must be avoided. A trend in blepharoplasty surgery has

emphasized periorbital fat repositioning rather than resection. Simply repositioning the herniated

periorbital fat over the inferior orbital rim, rather than resecting fat, can dramatically improve the

appearance of the lower eyelids.82 The approach of repositioning the orbital septum medially has

proven to be very helpful in eliminating tear–trough deformities. Once the periorbital fat has been

resected or repositioned, the skin/muscle flap is redraped superiorly and the redundant tissue is excised.

The lower eyelid wounds are closed with interrupted sutures of 6-0 silk. Ancillary procedures may also

be necessary to improve the position of the lower eyelid, including a medial canthoplasty, a lateral

canthoplasty, lateral canthopexy, or horizontal lid shortening. If a lower lid blepharoplasty is being

performed in conjunction with a rhytidectomy, the rhytidectomy should be performed first, so that the

amount of excess lower eyelid skin can be determined after the facial soft tissues have been elevated.

In younger patients, the tired appearance of the lower eyelids is commonly a result of excessive or

herniated periorbital fat. A lower lid blepharoplasty through a transconjunctival approach allows

removal or repositioning of the periorbital fat without an external scar. The conjunctiva is divided

transversely 1 mm above the sulcus to gain access to the orbital septum. The septum is divided and the

periorbital fat is removed or repositioned from all three compartments. Once again, the emphasis has

been to preserve periorbital fat and simply reposition the orbital septum into a more optimal location

obviating the need for fat resections. The transconjunctival incision is then allowed to heal by secondary

intention, allowing rejuvenation of the lower lids without an external incision.

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Figure 109-25. Cervicofacial rhytidectomy with superficial musculoaponeurotic system resection, platysma plication, submental

suction-assisted lipectomy, endoscopic browlift, and bilateral subciliary lower eyelid blepharoplasty. A, B: Preoperative

appearance. C, D: Postoperative appearance. Note the dramatic improvement in the appearance of her neck, flattened nasolabial

folds, improved definition of the mandibular border, and improved prominence of the malar regions.

Recently, a multiplanar approach for the rejuvenation of the lower eyelids has been employed to

reduce the incidence of lower eyelid ectropion postoperatively. These approaches combine both

subciliary incisions for removal of excess skin and transconjunctival incision for repositioning or

resection of the periorbital fat. Clinical case series from experienced plastic surgeons have demonstrated

outstanding outcomes with this approach.

Postoperatively, patients are evaluated in the recovery room for corneal abrasions, changes in visual

acuity, or hematomas, which may require emergent intervention. No vigorous physical exercise is

permitted during the early postoperative period. Artificial tears are used to maintain appropriate

lubrication. Sutures are removed 5 to 7 days postoperatively. Patients are informed that they will be

bruised and swollen for approximately 2 weeks and that it will be approximately 6 to 8 weeks before

the final result will be seen.

Rhinoplasty

Rhinoplasty is an exacting operation to alter the external appearance and internal anatomy of the nose.

The nose may be aesthetically unappealing or functionally impaired as a result of trauma, surgery, or a

congenital deformity. Clearly, many familial and ethnic traits result in a multitude of nasal appearances.

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As a result, it is crucial that the patient and surgeon discuss the goals of the procedure and the

likelihood of achieving those goals. The patient must have realistic expectations and be prepared for the

operation both physically and mentally.

To successfully achieve the goals of rhinoplasty, a complete nasal history is obtained with particular

attention paid to nasal airway obstruction, allergies, trauma, and previous surgery. A photographic

analysis is performed to evaluate facial and nasal dimensions. The photographs are examined with the

patient, the operative plan is discussed, and the potential structural and functional outcomes are

reviewed.83

Rhinoplasty may be performed under local or general anesthesia. The patient is prepared for surgery

by intranasal injections of vasoconstrictors containing lidocaine and epinephrine. Topical

vasoconstrictors are applied to the nasal lining and septum. The operation can be performed in an

“open” or “closed” fashion. The open technique requires a transcolumellar incision extended intranasally

to allow exposure of the cartilage and bones of the nose. Direct visualization of the structure of the nose

allows greater precision in cartilaginous sculpting, grafting, and nasal bone repositioning. The paired

lower lateral cartilages create the shape and provide the support for the nasal tip. Any deformity

involving the nasal tip requires manipulations of this cartilage, including resections for a bulbous or

overprojecting tip, suturing to reposition an asymmetric nasal tip, or cartilage grafting to increase tip

projection. The paired upper lateral cartilages and nasal bones define the shape of the nasal dorsum and

control nasal airflow. A prominent dorsal hump may require resections of both the upper lateral

cartilages and nasal bones. Osteotomies of the nasal bones may be required to narrow nasal width by

disconnecting the base of the nasal bones from the maxilla (Fig. 109-26). In contrast, “saddle nose”

deformities may require cartilage or bone grafting to provide dorsal augmentation. Alloplastic materials

have been described for use as dorsal grafts, tip grafts, or columellar struts to increase nasal projection.

However, many surgeons discourage use of such alloplastic grafts due to problems with infection,

extrusion, and migration producing a suboptimal result acutely or chronically. Autogenous cartilage

grafts from the nasal septum, ear, or rib may also be used to improve nasal appearance or airflow.

These grafts can be harvested and sculpted to create the desired cosmetic appearance of the nasal

dorsum and tip. “Spreader grafts” can also be placed between the nasal septum and the upper lateral

cartilage to increase the size of the internal nasal valve area, improving nasal airflow.84 The “closed”

rhinoplasty technique allows access to the nasal cartilage and bones through intranasal incisions. Many

experienced rhinoplastic surgeons prefer this less invasive approach. Unfortunately, it is difficult to

perform many of the complicated cartilage grafting and suturing techniques with this limited exposure.

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