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144. Isakoff MS, Bielack SS, Meltzer P, et al. Osteosarcoma: Current treatment and a collaborative

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Chapter 109

Plastic and Reconstructive Surgery

Christian J. Vercler, David L. Brown, Steven R. Buchman, Paul S. Cederna, Kevin C. Chung, Jeffrey H.

Kozlow, William M. Kuzon, Jr., Adeyiza O. Momoh, and Edwin G. Wilkins

Key Points

1 A variety of operative procedures have been described for breast reconstruction following

mastectomy. These approaches can be categorized as implant-based, autogenous (natural) tissue, and

“hybrid” procedures.

2 Currently, the most commonly performed of these procedures are based on the lower abdominal soft

tissue.

3 The absolute indications for replantation are (a) thumb amputation, (b) multiple finger amputations,

(c) pediatric population amputations, and (d) mid-hand, wrist, or distal forearm amputations.

4 Rigid skeletal fixation, revascularization using vein grafts, and immediate wound coverage are

crucial factors in successful limb salvage.

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

procedural planning, and precise execution of technically challenging procedures.

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.

7 A cleft lip deformity can be bilateral or unilateral and is considered complete if it extends into the

nose and incomplete if it does not. The cleft lip can extend into the gum partially or completely

through the alveolus, creating a bony defect. The cleft lip deformity affects the nose as well as the

lip, and therefore both of these structures must be addressed in the reconstruction of the deformity.

8 Craniosynostosis is defined as the premature fusion of one or more of the cranial sutures. The child

afflicted with craniosynostosis displays abnormalities in the size and shape of the cranial vault.

Plastic and reconstructive surgery can be defined as a discipline that addresses problem wounds using a

diverse array of nonsurgical and, especially, surgical therapies. In this definition, the term problem

wounds is taken in the broadest sense; plastic surgeons treat traumatic, congenital, developmental, and

even psychological wounds. Perhaps it is this latter aspect of plastic surgery that most fully sets it apart

from other surgical specialties:

We restore and make whole those parts which nature or ill fortune have taken away, not so much to

delight the eye but to buoy up the spirit of the afflicted.

—Gaspare Tagliacozzi, 1597

In more concrete terms, plastic surgery is an approach to surgical problems. Plastic surgeons operate

“from the top of the head to the tip of the toes,” and they envision themselves as surgical innovators.

Plastic surgeons have been instrumental in the development of microvascular surgery, craniofacial

surgery, head and neck reconstruction, nerve grafting, and even renal transplantation.1 Although the

field of plastic surgery can be arbitrarily divided into “cosmetic” surgery (surgery to improve the

appearance of a normal phenotype) and “reconstructive” surgery (repair of damaged anatomy or an

abnormal phenotype), in many circumstances, both functional reconstruction and aesthetic improvement

are paramount. Plastic surgery is truly “general surgery,” with a broad and growing list of

subspecialties (Table 109-1).

PRINCIPLES OF MANAGEMENT FOR PROBLEM WOUNDS

Regardless of the etiology or location of a wound, the principles of management are universal and can

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be embodied by a straightforward algorithm:

1. Evaluate and, if possible, eliminate the factors contributing to the presence of the wound.

2. Control or optimize the wound prior to closure.

3. Close the wound using the simplest method, unless specific factors mitigate a more complex

approach.

Although it is the nature of surgeons to focus on the technical details of operative procedures, the first

two steps in this algorithm are most critical for the successful reconstruction of problem wounds. This

algorithmic approach allows plastic surgeons to treat diabetic foot ulcers, infected sternotomy wounds,

major defects after composite resection of the head and neck, pressure ulcers, lower extremity wounds

after open tibial fractures, venous stasis ulcers, and other difficult defects with a high degree of success.

This rational approach is the core of plastic surgery. In plastic surgery there is no one-to-one correlation

between a surgical problem and a specific operation. There is no “right” way to reconstruct a given

defect, and a spectrum of options must be considered for every reconstructive problem. Selecting the

best option for a given patient is the challenge.

Evaluation of Problem Wounds

The evaluation of patients with difficult wounds is best approached using a systematic approach since

wounds are rarely secondary to only one isolated cause. Evaluation of both local and systemic (or

intrinsic and extrinsic) contributing factors within each portion of the work-up is critical. In the history,

local factors of importance include the mechanism that resulted in the wound, symptoms such as pain or

loss of function, the time course and progression of the wound, any previous nonsurgical or surgical

treatments for the wound, and any history of previous injury, irradiation, malignancy, or other local

factors that contributed to the presence of the wound. The history should also uncover systemic factors

that impair wound healing, including immunosuppression (e.g., chemotherapy, immune deficiencies),

medical conditions known to impair healing (e.g., diabetes, renal failure), medications (e.g., steroids,

cyclosporin A), cigarette smoking, and general debility (e.g., nutritional deficiencies, old age).

COMPLICATIONS

Table 109-1 The Spectrum of Plastic Surgery

The physical examination of patients with problem wounds should be focused on local and systemic

signs that affect wound healing. For the wound itself, the location, size, depth, exposure of deep or vital

structures, presence of necrotic material, presence of foreign bodies, or signs of any neoplastic processes

should be carefully noted. The clinician often needs to consider bacterial colonization and acute/chronic

infection as potential addressable causes. All open wounds will have bacterial colonization, but this by

itself does not designate a wound as “infected.” The diagnosis of infection is contingent on the physical

examination findings of local inflammation: erythema, pain, swelling, fluctuance, purulence, and loss of

function. Physical examination should be the primary criterion for the diagnosis of local wound

infection; surface swabs indicating the presence of pathogenic bacteria do not correlate with clinically

significant infection.2 In addition to the wound itself, surrounding tissue should be examined for signs of

injury (e.g., actinic changes), previous irradiation, arterial or venous insufficiency, lymphedema, loss of

sensation, and dermal thinning (e.g., aging, steroid therapy). For all wounds on an arm or leg, a careful

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neurovascular examination for the entire limb is mandatory. In addition to the local examination, a

focused systematic physical examination is mandatory in patients with problem wounds. Systemic signs

of infection (e.g., fever, hypotension) are of particular importance. Obesity is a major risk factor that

impairs wound healing. The general physical examination should focus on the systemic factors that

affect wound healing as noted previously. Table 109-2 lists some of the local and systemic factors that

impair wound healing; history and physical examination are the principal modalities for diagnosing

these problems.

Laboratory examinations can be invaluable in the management of problem wounds. However,

laboratory tests are often misused in wound patients, and a rational, evidence-based approach is

necessary to efficiently utilize this expensive resource. Again, the local–systemic paradigm is useful in

determining which laboratory examinations are warranted.

For local evaluation, wound swabs can be valuable for surveillance of the flora contaminating a

wound but should not be used as a trigger to initiate therapy for wound infection. Wound biopsy and

quantitative bacteriology have proved valuable in the management of burns and chronic wounds and

can provide both topical and systemic antibiotic sensitivities.3,4 Bacterial loads in excess of 105/g tissue

indicate contamination at a level that precludes skin graft take and jeopardizes wound closure of any

kind. The use of quantitative cultures, however, is not justified for most acute or uncomplicated chronic

wounds. In general, quantitative cultures are reserved for “high stakes” wounds, where a failure of

closure on the initial attempt may leave an unreconstructable situation with grave consequences, such as

amputation or death. Wound biopsies can be invaluable for diagnosing invasive burn wound infection

and are preferred over quantitative culture for this purpose.5 The presence of bacteria in the deep

dermis on biopsy is highly correlated with the risk of systemic sepsis in burn patients. Bone biopsy

demonstrating bacteria within the bone is the gold standard test for making the diagnosis of

osteomyelitis. Standard radiographs are most useful for diagnosing and delineating acute fractures and

are much less useful in the setting of chronic, open wounds. Ultrasound, computed tomography (CT)

scan, or magnetic resonance imaging (MRI) may be useful for delineating fluid collections, necrotic

tissue, or inflammation in selected circumstances. In contrast, radionuclide bone scans have little role to

play in patients with open wounds or fractures. In the face of an open wound or recent fracture, a “hot”

bone scan (even a triple-phase bone scan) is not specific for osteomyelitis and has little value.

Therefore, obtaining bone scans in patients with suspected sternal osteomyelitis after recent midline

sternotomy, in pressure sore patients with exposed bone, or in other patients with open wounds

overlying exposed bone is unwarranted. Under these circumstances, bone biopsy is preferred for making

a diagnosis of osteomyelitis and for determining the responsible pathogen; MRI is preferred for

delineating the extent of bony involvement. Computed tomography angiography (CTA), magnetic

resonance angiography (MRA), or standard angiography may be indicated if vascular insufficiency is

suspected or if a free-tissue transfer is planned. The choice of modality depends on both patient and

health system-based factors.

CLASSIFICATION

Table 109-2 Local and Systemic Factors That Affect Wound Management

The use of systemic laboratory investigations should be limited to specific indications; “routine” blood

work is not required for patients with acute or chronic wounds. White blood cell differential counts and

blood cultures can confirm the diagnosis of systemic infection. Serum prealbumin may be valuable in

determining nutritional status. A greatly elevated erythrocyte sedimentation rate and C-reactive protein

can help confirm the diagnosis of osteomyelitis or be used to monitor treatment response. Other

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laboratory tests to confirm the diagnosis and severity of associated medical conditions may be justified

for specific indications.

Treatment of the Problem Wound

Once a wound has been fully evaluated, the treatments should be designed to address any modifiable

causes for the wound and then to achieve specific targeted goals. In order of greatest priority, these

goals are: (a) prevention of complications resulting from the wound, (b) preserving or restoring critical

functions, (c) achieving wound closure, and (d) restoration of aesthetics.

Preventive Treatment

The preventive measures that should be taken for patients with open wounds depend on the setting. For

an acute laceration, tetanus prophylaxis should be considered. For patients with pressure sores, a strict

adherence to pressure-relief protocols, optimization of wheelchair seating/bedding, optimization of

social support and wound care, and an assessment of nutritional status take priority. In wounds caused

by human or animal bites, prophylactic antibiotics are warranted. In addition, any associated medical

conditions that are contributing to the wound must be aggressively optimized including glucose control,

vascular disease, and contributing medications. It is the responsibility of the surgeon to ensure that a

patient with a wound does not develop a complication from that wound and that the patient does not

develop more wounds from the same mechanism. This is of particular importance in bedridden,

obtunded, or paralyzed patients, in whom it should be possible to completely prevent pressure sores

with proper nursing or family care.

Preservation of Function

Preserving joint motion must always be considered for patients with open wounds of the extremities.

Aggressive physiotherapy to maintain or improve joint motion can be instituted in the presence of an

open wound. Splinting should be used to minimize joint contractures and any plans for wound closure

should include measures to maintain joint function. In the case of facial defects, especially if facial

paralysis is present, oral competence and the maintenance of eye protection should weigh heavily into

any reconstructive plan. Function takes precedence over form in the reconstructive algorithm.

Nonsurgical Therapy

After careful consideration of preventive measures and the preservation of critical function, a strategy

for wound closure can be formulated. The basic tenet is: “débride dirty wounds, close clean wounds.”

Therefore, the first step in wound closure is achieving control of the wound by eliminating necrotic

debris and controlling any infection present. Nonsurgical therapies are used in conjunction with surgical

therapy to achieve a clean wound. The mainstay of local, nonsurgical therapy is the use of wound

dressings. It is beyond the scope of this chapter to review the wide range of options available to dress

wounds. Recent articles contain a contemporary review of this topic.6–8 However, the basic principle is

to employ débriding dressings for dirty wounds and occlusive dressings for clean wounds. The most

commonly employed débriding dressing is the “wet-to-dry” dressing. Gauze made damp with normal

saline, weak acetic acid, weak bleach, or various other solutions is applied to the wound. Over a period

of hours, evaporation dries the dressing, which becomes slightly adherent to the wound surface. When

the dressing is removed, necrotic debris and biofilm is removed with the dressing, but healthy tissue is

left behind. Wet-to-dry dressings work through mechanical débridement, and the most important

component of their use is how often they are changed. Wet-to-dry dressings must be changed a

minimum of twice per day, although more frequent dressings may be necessary in certain wounds.

These dressings should not be “soaked” off to reduce patient discomfort because this technique

completely defeats their purpose. Enzymatic dressings have also been used to débride wounds, but their

use can be limited by patient tolerance to the pain they cause. Débriding dressings are indicated for

infected wounds and wounds containing necrotic debris.

If a wound is “clean,” meaning that it does not contain necrotic debris and has an acceptable bacterial

load, a dressing that maintains a moist wound environment to encourage wound healing should be

used.8 For many simple wounds, allowing a scab to provide the moist healing environment or the

application of a nonadherent sterile dressing is all that is required. In the case of more complex wounds,

occlusive dressings that maintain a moist environment to maximize wound healing are preferred.

Options include hydrocolloid dressings, alginate dressings, and various hydrogels. Again, occlusive

dressings must not be used on infected or dirty wounds. For many wounds, judicious application of

hydrocolloid dressings may allow closure by secondary intention in a reasonable period of time.

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Under some circumstances, it is appropriate to use antibiotic dressings. Multiple combinations of

topical antibiotics are available over the counter and generally cover gram-positive bacteria. Mupirocin

ointment has the added benefit for treating methicillin-resistant staph aureus (MRSA) colonization. Burn

wounds are most commonly dressed with silver sulfadiazine or mafenide acetate due to their high

antimicrobial activity. The low toxicity and excellent antibiotic properties of elemental silver have led

to the development and widespread use of wound dressings containing nanocrystaline silver including

both barrier dressings and in combination with alginates for daily wound care. In general, however,

antibiotic dressings are not required for clean wounds, even if they are chronic.

Finally, it should be noted that we are entering a new era of nonsurgical wound management. A rapid

advance in our understanding of wound healing has led to the development of growth factor therapy,

cellular therapy, and new physical modalities for the treatment of chronic wounds.6 Although

recombinant platelet-derived growth factor appears to be a useful adjunct to the dressing regime for

pressure sores and diabetic foot ulcers,9,10 there is general agreement that exogenously administered

growth factors currently play a limited role in the management of acute and chronic wounds.11

Similarly, laboratory data point to the potential for the use of stem cells as a modality to treat difficult

wounds, but cellular therapy for clinical wounds is still largely investigational.6,12

There has also been an increase in tissue-engineered dressings and skin substitutes.13,14 For example,

Integra (Integra Life Sciences Corp., Plainsboro, New Jersey), a bilaminar skin substitute composed of a

collagen matrix base with a silicone rubber barrier layer has proven extremely useful in the

management of complex wounds and allowing for granulation tissue in compromised wound beds in

burns, trauma, and oncologic resections. The development of human, bovine, and ovine acellular dermal

matrices are being used in wound care and structural reconstruction of the abdominal wall and breast.15

The development of new tissue-engineered adjuncts to wound healing remains a very active area of

research in plastic surgery.

Negative-pressure wound therapy has become more widespread and can be efficacious and cost

effective when applied appropriately for complex wounds.16–18 Multiple commercial products exist, but

all are similar in the use of a sponge-like material connected to a suction device. There is additional

variation in sponge material and inclusion of antimicrobial silver that can be used in specific clinical

situations. Extensive experimental and clinical data confirm that the negative-pressure wound therapy

promotes tissue perfusion, reduces edema, favorably alters wound fluid composition, and stimulates the

formation of granulation tissue.18 Although these systems are easy to use, decrease the frequency of

dressing changes, and can manage edema fluid, their use is contraindicated in acutely infected wounds

and requires clinical judgment in balancing the tradeoff between negative-pressure therapy and other

wound control methods.

Multiple other modalities, such as hyperbaric oxygen treatment, are in use and are being developed

on an ongoing basis, underscoring the high prevalence, the significant cost, and the clinical challenge

that are posed by complex wounds. Despite these ongoing developments, the basic algorithm for

evaluation and nonsurgical management of wounds will not change.

Surgical Therapy

Wound Preparation. For problem wounds, surgical therapy is primarily aimed at wound preparation

and wound reconstruction. For dirty wounds with necrotic debris, a judicious but thorough surgical

débridement can convert a contaminated, chronic wound into a fresh surgical wound ready for

immediate closure. Although débriding dressings can prepare wounds for closure under some

circumstances, an operative débridement is preferred to a long course of débriding dressings for most

problem wounds. Consequently, most complex wounds require an operative débridement prior to

definitive reconstruction. In the case of chronic osteomyelitis, a formal resection of the sequestrum is

required before formal wound closure. Prolonged treatment with intravenous or oral antibiotics cannot

clear bacteria from a focus of dead bone; chronic osteomyelitis is a surgical disease cured with a saw,

rongeur, bur, or bone curette. Therefore, the common practice of placing patients with chronic

osteomyelitis on 6 weeks of antibiotic therapy is irrational unless performed in conjunction with a

formal sequestrectomy.

ETIOLOGY

Table 109-3 The Reconstructive Ladder

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Reconstructive Principles. As stated earlier, there is no “right” way to close any given wound. Plastic

surgeons use a straightforward set of principles in delineating the optimum way to close a given wound

for a given patient. The predominant principle is that the simplest method to close a wound is usually

the best choice. This principle is embodied in the “reconstructive ladder,” which is a hierarchy of

reconstructive options progressing from simple to complex (Table 109-3). Therefore, when engaging

options for wound closure, plastic surgeons “climb” the reconstructive ladder, usually stopping on the

lowest rung that will achieve a closed wound. However, other principles of reconstruction sometimes

override a slavish adherence to the reconstructive ladder. The choice of a technique for wound closure

should take into consideration the need for subsequent procedures and other factors that might mitigate

skipping over simpler options for wound closure. An example would be an avulsion injury to the palm

of the hand. Although it might be possible to close this wound with a skin graft, the need to restore

flexor tendon function is preeminent in the hand, so that the use of a distant flap to provide a suitable

bed for tendon grafting may be the preferred choice. In addition to the reconstructive ladder, other

examples of guiding reconstructive principles are: function takes precedence over form, single-stage

reconstructions are preferred over multistage approaches, and autologous tissue is preferred over

alloplastic reconstructions. Other factors to be considered are the durability of the reconstruction over

many years, the psychological impact on the patient, and data indicating that some options are

sometimes preferred for specific reasons. For any reconstruction, the surgeon must carefully consider

the potential secondary consequences of the reconstructive technique and morbidity at the donor site.

The increased identification of alternative flap donor sites with less morbidity reconstruction has

changed the reconstructive paradigm to sometimes use a “reconstructive elevator” to higher-level

reconstructions to better address the secondary reconstructive outcomes. Thus, weighing this complex

array of factors to arrive at the optimal reconstruction for a given patient is the true challenge in

reconstructive surgery.

Reconstructive Techniques. Regardless of the reconstructive method chosen, plastic surgeons strive

for technical virtuosity in the operating room. To maximize healing and minimize scar formation,

atraumatic technique includes delicate tissue handling, the use of skin hooks and sharp rakes, bipolar

electrocautery, sharp dissection, and loupe magnification. When reconstructing difficult wounds, the

margin for error is minimal, and small errors in technical execution can result in failure. It is also

critical that secondary plans for reconstruction are considered and preserved during an initial

reconstructive attempt. The general surgical methods used by reconstructive surgeons are briefly

considered in this chapter.

An important distinction is made between a graft and a flap. A graft consist of tissue that is

transferred into a defect in a devascularized state and requires a vascularized environment and

subsequent vascular ingrowth in order for incorporation. Skin, fat, muscle, tendon, fascia, cartilage, and

bone can all be used as grafts; however, the volume of each that can be successfully incorporated

depends on the surrounding wound environment and the physiologic principals of each tissue. In

contrast, flaps consist of tissue that is transferred while remaining vascularized. Flaps are much less

dependent on the local environment for survival given the inherent blood supply and can be used when

immediate coverage is necessary or when the underlying defect will not support a graft. Free tissue

transfer (or a “free flap”) is the transfer of tissue on a single vascular pedicle which is immediately

anastomosed at the recipient site allowing for the transfer of vascularized tissue from a separate area of

the body.

Primary Closure. If a laceration or other wound can be closed primarily, consideration is given to a

meticulous, layered closure. Emphasis is placed on eversion of skin edges without strangling tissue.

Nonabsorbable skin stitches that provoke minimal inflammatory response are preferred, but they must

be removed promptly to minimize cross-hatching. Therefore, for most wounds, deep dermal, absorbable

stitches are placed to allow early removal of skin stitches while still providing prolonged support to the

repair; this may minimize the chances of a dehiscence or scar spread. It is preferable to place a closed

suction drain to eliminate dead space rather than suturing fat or other easily devascularized tissue. If a

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