Investigations

•CT (gold standard)

axial and coronal (specifically request 1.5 mm cuts):for fractures of upper, middle, and lower face

indicated for significant head trauma,suspected facial fractures, and preoperative assessment

•panorex radiograph:shows entire upper and lower jaw; best for isolated mandible fracture, but patient

must be able to sit; however, if high clinical suspicion and negative panorex, CT should be done

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Treatment Goals

• re-establish normal occlusion if occlusion is an issue

• normal eye function (extraocular eye movements and visual acuity)

• re-establish facial height and width to re-establish appearance

• consultation when indicated (dentistry, ophthalmology, neurosurgery)

5. Lower transverse maxillary (4 palatel

8. Pterygomaxillary

9. Posterior vertical

6. Upper transverse mandibular

7. Lower transverse mandibular

Figure 27. Craniofacial horizontal and vertical buttresses

Mandibular Fractures

•two points of injury since it is a ring structure (includes fractures and dislocations)

•commonly at sites of weakness (condylar neck, angle of mandible)

Condyle Subcondyle

Etiology

•anterior force: bilateral fractures

•lateral force: ipsilateral subcondylar and contralateral angle or body fracture

• note: classified as open if fracture into tooth bearing area (alveolus)

Ramus

“

"

"1Symphysis

Parasymphysis

© Susan Parle 2009

Clinical Features Angle

•pain,swelling, difficulty opening mouth (“trismus”)

•malocclusion, asymmetry of dental arch

damaged,loose, or lost teeth

•palpable “step” along mandible

• numbness in CN V3 distribution

•intra-oral lacerations or hematoma (sublingual)

•chin deviating toward side of a fractured condyle

Classification

Body

Figure 28. Mandibular fracture sites

Table 25. Mandibular Fracture Classifications by Anatomic Region

Areas/Boundaries

Symphysis Mid line of the mandible: between the central Incisorsfrom the alveolar processthrough the interior border ol the

mandible

From the symphysis to the distal alveolar border of the third molar

Triangular region betvreen the anterior border oi the masseter and the poslerosuperior insertion of the masseter distal

to the third molar

Part of the mandible that extends posterosuperiorly into the condylar and coronoid processes

Area of condylar process of mandible

Area below the condylar neck ( i.e.sigmoid notch) ol the mandible

Area ol the coronoid process ol mandible

Body

Angle

Ramus

Condylar*

Subcondylar

Coronoid Process

r -\

'Moxl common mandibular Iracturu type L J

Treatment

• maxillary and mandibular arch bars wired together (intermaxillary fixation) or ORIF (indications

depend on whether fracture is unilateral/bilateral, etc.); ideally managed within -18 h

• antibiotics from initial presentation until at least 3 doses postoperativelv; if late presentation, may

consider treatment with antibiotics for an extended course

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Maxillary Fractures

Table 26. Le Fort Classification

Le Fort I Le Fort II Le Fort III

Alternative Name Pyramidal fracture

Pyramidal

Nasal bones

Medial orbital wall

Pterygoid plates

Manila

Maxilla dividedInto 2 segments Maxillary teeth and midscctlon ol the

maxilla separated Irom upper lace

Guerin fracture

Horizontal

Piriform aperture

Maxillary sinus

Pterygoid plates

Craniofacial disjunction

Transverse

Nasofrontal suture

2ygomaticofronlal suture

Pterygoid plates

Zygomatic arch

Entire midfacial skeleton detached

from cranial base

Type of Fracture

Structures Involved

Le Fort Fractures

Anatomical Result

Nasal Fractures Le Fort II Fractures

Etiology

• lateral force -> more common

• anterior force -> can produce more serious injuries

• most common facial fracture

Clinical Features

• epistaxis/hemorrhage,deviation/flattening of nose,swelling, periorbital ecchymosis, tenderness over

nasal dorsum, crepitus,septal hematoma, respiratory obstruction,subconjunctival hemorrhage

Le Fort III Fractures

Figure 29. Le Fort fractures

Treatment

• treated for airway or cosmetic issues

• always inspect for, and drain,septal hematoma as this is a potential cause of septal necrosis and

perforation - completed with small incision in the septal mucosa followed by packing

• closed reduction with Asch or Walsham forceps under anesthesia, pack nostrils with petroleum or

non-adhesive gauze packing, nasal splint for 7 d

• best reduction immediately (<6 h ) or when swelling subsides (5-7 d)

• rhinoplasty may be necessary later for residual deformity (30%)

Zygomatic Fractures

Classification

1. fracture restricted to zygomatic arch

2. depressed fracture of zygomatic complex (zygoma)

3. unstable fracture of zygomatic complex (tetrapod fracture)

-separations occur at maxilla,frontal

bone, temporal bone, and orbital rim

Clinical Features

• 3 most common features (pathognomonic):

• subconjunctival hemorrhage

• periorbital ecchymosis (often associated with fractures of the orbital floor)

• CN V2 numbness (infraorbital and superior dental nerves)

• flattening of malar prominence (view from above)

• pain over fractures on palpation

• palpable step deformity in bony orbital rim (especially inferiorly)

• ipsilateral epistaxis; trismus

• ophthalmologic evaluation ifsuspected globe injury

Treatment

• if non-displaced,stable, and no symptoms, then soft diet; no treatment necessary

• non-displaced zygomatic arch fractures can be elevated using Gillies approach (leverage on the

anterior part of the zygomatic arch via a temporal incision) or Keane approach (elevation through

upper buccal sulcus incision) only if arch is not comminuted

• if arch is comminuted, coronal incision and ORI1-

'

is required

• OKU- for displaced or unstable fractures of zygomatic complex (route is dependent on location of

fracture)

tozygomatic

ygomatic arch

stico-maxillary

S.3 i

' ? j- .. 2c:9

Figure 30. Zygomatic fractures

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Orbital Floor Fractures

•see Ophthalmology,OP-12

Definition

•fracture of floor of orbit:may be a “pure blow-out fracture,” which has an intact orbital rim,or can be

associated with other fractures(orbital rim fracture and/or zygoma)

Etiology

•blunt force to eyeball (e.g.baseball or fist) -> sudden increase in intraorbital pressure

Clinical Features

•restricted tOM (if muscle trapped)

•periorbital edema and bruising,subconjunctival hemorrhage

•ptosis,exophthalmos, exorbitism, enophthalmos, and hypoglobus may be present

•diplopia may be present

•orbital rim step-offs with possible infraorbital nerve anesthesia

•orbital entrapment

clinical diagnosis that is a surgical emergency

• diplopia with straight gaze: unable to look up past neutral (entrapment of inferior rectus),limited

hOM

severe pain or N/V with upward globe movement

Investigations

•CT (diagnostic):axial,coronal,and sagittal views - with fine cuts through orbit:rounding of inferior

rectus can be a sign of orbital entrapment

•diagnostic maneuver for entrapment is forced duction test (pulling on inferior rectus muscle with

forceps to ensure full ROM) under general anesthesia in the OR

Treatment

•surgical repair indicated if:entrapment, any size defect with enophthalmos(if patient is bothered by

it),or persistent diplopia (>10 d)

•reconstruction of orbital floor with bone graft or alloplastic material (e.g. titanium meshes, MEDPOR',

MEDPOR TITAN*)

•after repair, many patients can have diplopia forseveral weeks

Complications

•persistent diplopia

•enophthalmos

Superior Orbital Fissure Syndrome

•fracture of SOF causing ptosis, proptosis, anesthesia in CN V1 distribution, and painful

ophthalmoplegia (paralysis of CN III, IV, VI)

•uncommon complication seen in Le Fort 11 and 111 fractures(1/130)

•recover)’ time reported as 4.8-23 wk following operative reduction of fractures

Orbital Apex Syndrome

•fracture through optic canal with involvement of CN 11 at apex of orbit

•symptoms are the same as SOF syndrome plus vision loss

•treatment is steroids or urgent decompression of fracture in optic canal (posterior craniotomy for

decompression)

Figure 31. Blow-outfracture

Traumatic Auricular Hematoma (Cauliflower Ear)

Definition

• trauma to the auricle that creates a subperichondrial hematoma that, if not corrected quickly, will

form a permanent disfiguring nodularity known as “cauliflower ear”

Epidemiology

• higher prevalence in athletes who participate in contact risk sports(e.g.mixed martial arts,boxing);

however,it is not exclusive to athletes

Clinical Features

• painless orslightly tenderswelling of the upper aspect of the pinna

• becomes firmer and harder with time if left untreated

• colour is skin-coloured orslightly bluish

Differential Diagnosis

• relapsing polychondritis, auricular pseudocyst, epidermoid cyst

Treatment

• aspiration,incision and drainage, and splinting of the auricular hematoma within 7 d ( preferably first

72 h)

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Breast

Anatomy

Vascular Supply

Subclavian artery

Thoracoacromial artery

Axillary artery

Lateral thoracic artery Internal thoracic artery

Thoracodorsal artery

Internal thoracic perforating branches

/

Medial intercostal perforators

Anterolateral intercostal perforators

CMidoiiNodigui 2016

Figure 32. Breast vasculature

Innervation

• innervated in a dcrmatomal pattern from branches of the thoracic intercostal nerves (T3-6)

medially innervated from anterior cutaneous branches of l

-VI intercostal nerves

laterally innervated from lateral cutaneous nerve branches of 1I-VI1 intercostal nerves

• lateral and upper portions of the breast innervated by lower fibres of the cervical plexus (C3,C4)

. NAC

supplied by anterior and lateral cutaneous branches of intercostal nerve IV

additional innervation by cutaneous branches of intercostal nerves III and VI

Intercostobrachial nerve,

Cervical plexus

Anteromedial

-intercosal

nerves

Anterolateral

intercostal _

nerves

3D Ruth Chang 2016

Figure 33. Innervation of the breast

Breast Reduction

Indications

• symptomatic (general symptoms)

musculoskeletal pain (back,bra strap location, neck), chronic headache, paresthesia in upper

limb, rashes/irritation under the breast, breast discomfort, and physical impairment

• breast reduction methods can be classified based on pedicle (i.e. blood supply to the NAC) and skin

resection pattern (i.e. the resultant scar)

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A

B

Inferior pedicle C

technique

Superior pedicle

technique

Superomedial pedicle

technique

Figure 34. Inverted T (“Wise”) pattern reduction

D

E

Figure 35. Vertical pedicles for breast reduction

John R.Fowler.Nandkinnar M. Rawed.Ultrasound ot the Hand and Upper Extremity 1st ed. 2017.Tieme Publishers, www.thicme.com (reprinted

with permission)

F

Common Types of Pedicles

•inferior pedicle: derived from the fourth, fifth, and sixth intercostal perforators; most commonly used

with the inverted T (“Wise") pattern reduction; versatile in small-large breast reduction

recommended pedicle width 6-8 cm, 8-10 cm in large breasts

•superior pedicle:derived from the internal mammary perforator of the second intercostal space

•medial pedicle: blood supplied by internal mammary perforatorsfrom third intercostal space,and

may have contribution from fourth intercostal space

•superomedial pedicle:incorporates the descending artery from the second intercostal space as the

medial pedicle base extendssuperolaterally to the breast meridian

•bipedicle: used in McKissock'

s technique (well-vascularized dermal-parenchymal vertical bipedicle)

Figure 36. Skate flap

A) incision outline

B) elevation of wings

elevation of entire flap

caudal folding of flap

skate flap with primary

C)

D)

E)

closure of donor site

F) with skin graft Table 27. Type of Skin Resections/Scar Options

Indications Description

Commonly used in association with inferior pedicle

large portion ol skin removed in horizontal and vertical dnection

Inverted!Pattern large breasts

Breasts with poor gualilyskin that are

challenging to remodel

iamotoi ol nipple

co

<N

-yi

•

gSkin integrity important toshape and hold breast parenchyma

Used in association with superior or medial pedicle

Parenchyma needed to shape skin

Ho horizontal scar

Vertical eight Pattern Surgeon preference of nipple

i

Circumference £

of nipple Complications

NAC necrosis

sensory alteration of nipple (may vary with type of pedicle) (may increase or decrease)

unsatisfactory scarring, including hypertrophic or keloid scar

wound healing complications ( 1-5% in healthy patients, higher in patients with elevated BMI )

hematoma

wound infection

fat necrosis

asymmetry of breasts and NAC

potential inability to breastfeed

r m

Figure 37. C-V flap L J

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Mastopexy (Breast Lift)

Definition

• aesthetic procedure of the breast used to correct breast ptosis by modifying the contour and size of the

breast along with elevating the position of the nipple

Clinical Grading of Ptosis (Regnault Ptosis Grade Scale)

1. minor ptosis (Grade I )

nipple at inframammary fold

2. moderate ptosis (Grade 2)

nipple below inframammary fold, but above lower breast contour

3.severe ptosis (Grade 3)

* nipple below inframammary fold and at lower breast contour

4. glandular ptosis/pseudoptosis

ptosis of the lower pole of the breast where the NAC is at or above the inframammary fold

Choice of Incision

• mastopexy can be performed through the same incisions as breast reductions

Breast Augmentation

Definition

• procedure designed to increase the size of the breast

Choice of Incision

• position of incision individualized since no single incision is best for all patients

• 3commonly used types of incision:periareolar, inframammary crease,transaxillary

Type of Implant

• silicone orsaline-filled

• subclassified into various styles ofsurface and shape

Location of Implant

• implants are commonly placed in the following positions:

1.submuscular

implant placed deep to the pectoralis major muscle

most commonly in patients that do not have enough tissue to cover the implant

2.subglandular

implant placed deep to glandular breast tissue but superficial to muscle

3.subfascial

implant placed below the pectoralisfascia

Complications

• hematoma, infection, capsular contracture, leakage rupture, aesthetic deformity

• breast implant illness

. BIA-ALCL

* increased risk of BIA-ALCL with textured implants

• presents assudden onset of pain without injury, or assudden onset of seroma on average 7-8 yr

alter use ofa textured implant for reconstruction or augmentation purpo

etiology:several theories, including implant-induced chronic inflammation, chronic biofilm,

reaction to silicone shards,and causes not yet determined

risk estimated by Health Canada to be 1/3565 for Allergan Biocell* macro-textured implants and

1/16703 for Mentor* Siltex* micro-textured implants (Health Canada safety alert KA-70045)

management: en bloc resection of the implant and capsule;standard secondary therapy includes

brentuximab

• favourable clinical outcome if detected and treated early

ses

Gynecomastia

Definition

• benign enlargement of the male breast due to proliferation of the glandular tissue r n

LJ

Clinical Classification

• gynecomastia can be further classified into:

1.idiopathic

2. physiologic

neonatal:circulating maternal estrogens via placenta

pubertal:relative excess of plasma estradiol vs. testosterone

elderly:decreased circulating testosterone, peripheral aromatization of testosterone to

estrogen

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3.pathologic

endocrinopathies:excess estrogen, androgen deficiency,deficient testosterone production or

action

tumours

chronic disease:liver cirrhosis, renal

congenital/genetic: Klinefelter'

ssyndrome, androgen resistance

4. pharmacologic

drugs that may interfere with estrogen-testosterone balance including:

- hormones (estrogens,gonadotropins, exogenous steroids)

- antiandrogens

- androgen receptor antagonists (steroidal and non-steroidal)

- androgen synthesisinhibitors (5a-reductase inhibitors)

- antigonadotropins (GnRH analogs, estrogens)

- recreational drugs (cannabis, heroin, amphetamines)

- antihypertensives(spironolactone)

5.massive weight gain

•for physical exani, investigations, and medical management,see Endocrinology. E34

Surgical Options

•surgery is the accepted method of management for gynecomastia

•surgery addresses the three components: breast tissue,fat,skin

•often involves a combination of liposuction (to remove the fatty portion) and surgical excision through

a small periareolar incision (to remove the glandular component)

•patients with significantskin excess may require skin excision as well

Breast Reconstruction

• use of alloplastic devices or autogenous tissue to reconstruct breast after cancer or trauma

• reconstruction can be performed immediately (at the same time as mastectomy) or delayed (as a

separate surgery months or years after initialsurgery)

• there are alloplastic and autogenous methods of reconstruction, each with its advantages and

disadvantages

Table 28. Timing of Immediate Reconstruction vs. Delayed Reconstruction

Advantages Disadvantages

Immediate

Reconstruction

Generally best aeslhetic outcome; maypreserve nipple il

oncologically sale

Docs not require creation of additionalskin

Tissues are not damaged Irom scarring

Good option lor patients unable lo have Immediate

reconstruction

Mastectomy flap viability can compromise outcome

longer surgical time

loss of skin, volume, lateral border of breast, and natural

landmarks, including inframammary fold (makessurgery

more challenging)

Resection of irradiated/scarred skin and associated wound

Delayed

Reconstruction

For patientswho may be getting radiotherapy and

undetermined post-surgery oncologic treatment

Provides option of contralateralsurgery with reconstruction, healing complications,including risk of reconstructive

if required (I.e.contralateral cancer, genetic marker for failure

disease) Likely requires more stages than immediate reconstruction

lor completion

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Table 29. Alloplastic Reconstruction vs. Autogenous Reconstruction

Advantages Disodvantagcs

Alloplastic Reconstruction Single stage direct to implant (Oil) Shorter surgery

May give a more complete or

(tnal result

Sice restriction in reconstruction

Very lew patients meet criteria:

Grade 1 ptosis,small breast,skinsparing mastectomy

Less tension on mastectomy Requires multiple OR procedures

flaps compared to single-stage and clinic visits

reconstruction with implants Waiting time between first and

Ability to increase amount olskin second stages

and avoid use of flap

Some patient control over final

outcome

Twostage reconstruction with

expander and implant

Requires post-surgical procedures

(patient to come to clinic for

inflations)

Sice of reconstruction limited

to mastectomy Rap sice and

vascularity

Acellular dermal matrix and

implant

Can cover areas of implant or Animation it submuscular

tissue expander and place It above

muscle (no muscle dissection

required)

Can create larger submuscular

pocket for bigger device

Can be done as a

free tissue transfer or as a

pedided TRAM

Provides a good amount of tissue

for transfer in most patients

Similar to well concealed “tummy Pedided 1RAM:

Higher bulge rates

Higher rate of flap necrosis

Autogenous Reconstruction Transverse Rectus Abdominis

Myocutaneous (TRAM) flap

Abdominal scar

Volume depends on patient's

donor site

Weakness in rectus abdominis

luck" scar

Free TRAM:

Requires preparation of recipient

vessels and microsurgical

anastomosis

Method spares rectus abdominis dependent on amount of

muscle and fascia and should abdominal tissue available

theoretically preserve Innervation Abdominal scar

and continuity of abdominal wall

Reliable pedicle

Providesskin and muscle

Possible to do muscle sparing

procedure without flap

compromise

Good option if abdominal tissue

notsufficient

Upper part of buttock Musclesparing

Can remove extra tissue from

flanks to reduce abdominal

circumference

Lower part of buttock

Muscle-sparing

DILP

Latissimusdorsi flap Hollowness at harvest site

Shoulder weakness or impaired

shoulder range of motion

Dorsal hernia

SGAP Short pedicle length

More technically challenging than

TRAM and DILP

IGAP Contour of buttock is allectcd

Short pedicle length

More technically challenging than

TRAM and OILP

Not amenable tolarge breast

reconstruction

Short pedicle length

Potential damage to lymphatic

drainage of leg

TUG Good option if abdominal and

buttock tissue notsulfident

Scar is well hidden within groin

crease

Gracilis muscle not critical for

strength

Good option if abdominal and

buttock tissue notsufficient

Muscle-sparing

Scar is hidden within/beneath

gluteal sulcus

PAP Not a menable tolarge breast

reconstruction

May have altered sensation in

posterior thigh

Nipple Areolar Complex Reconstruction

• nipple reconstruction is usually done as the final step when the patient is satisfied with breast mound

creation

• reconstruction can he performed with local anesthetic since many patients have decreased sensation

in the mastectomy or breast (laps

• it can be done by either a llap, graft, or 3D tattoo

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Table 30. Types of Nipple Reconstruction

Description Advantages Disadvantages

Skate Flap Pedicle elevated above breast mound

Lateral aspects olflap are wrapped around central

aspect of flap

Delect mainly closed byskin gralt

Lossolprojection

Donor site morbidity

May have loss olprojection over

Low complication rates

time

Skin gralt required

Ulilites C flap and two V flaps lot nipple

reconstruction

Diameter ol C flap becomes diameter of

reconstructed nipple

Width of V flaps dictate projection of reconstructed

nipple

C-V flap closed with primary closure

Tissue commonly from contralateral nipple (nipple

share) orlabia

Two methods for nipple gralt:

• Distal aspect of nippleremoved transversely and

delect closed with purse siting suture

• Nipple divided inhall longitudinally, folded over,

and closed with primary closure

loss olprojection

Nipple sice limited by flap

dimensions

C-V Flap Nogralts required

May have loss of projection over

time

Tattooing required tomatch

natural areola

Nipple Graft Loss of projection

Donor site morbidity

Decreased contralateral nipple

sensation

Necrosis olgralt or donor nipple

Nipple share isan excellent option

in patients with contralateral

nipple projection >1cm

Table 31. Types of Areolar Reconstruction

Description Advantages Disadvantages

Conducted 3-4 mo after nipple

reconstruction when most of the

projection has stabilized

Full thickness skin grails,

commonly frominner aspect ol

thigh or opposite areola

Can provide more accurate colour May require touch-ups due to

matching withlimited morbidity pigment lading overtime with skin

sloughing

Provides texture and pigment Donor site morbidity

resembling a natuial areola

Tattoo"

Skin Graft’

‘Tattoo and skin grlilting can be usedIn conjunction

Aesthetic Surgery

Aesthetic Procedures

Table 32. Aesthetic Procedures

Location Procedure Description

HeadfNeck Hair transplants

Otoplasty

Foreheadfbrow lift

Rhytidectomy

Blcpharoptasty

Aesthetic improvement of hair growth patterns using hair follicle grafts or flaps

Surgicalreconstruction of external ear

Surgical procedure to lift the forehead and eyebrows

Surgical procedure lo reduce wrinkling and sagging olthe lace and neck;“face lift"

Surgical procedure lo shape or modify the appearance oleyelids by removing excess eyelid

skin tlalpads

Surgicalreconstruction olthe nose tnasal aiiway

Chin augmentation via osleolomy oi synthetic implant toimprove contour

Application ol oneor more exfoliating agents to the skin resultingin destruction olportions

of the epidermis and/or dermis with subsequent (issue regenerabon

Skin resurfacing with a rapidly rotating abrasive tool;often used lo reduce scars,irregular

skin surfaces,and fine lines

Application ol laser to the skin which ultimately results in collagen reconfiguration and

subsequent skin shrinking and tightening:often used lo reduce scars andwrinkles

An injectable substance is usedlo decrease facialrhytids;can augmcnl lips to create fuller

appearance; substances include: collagen, fat. hyaluronic acid,and calcium hydioxyapatile

(most common substances include hyaluronic acid and fat)

Removal olexcess skin and repair of rectus muscle laxity (redus diastasis);"lummy luck"

Augmentation of calf muscle with implants

Surgical removal of adipose tissue lor body contouring (not a weight loss procedure)

Rhinoplasty

Genioplasly

Skin Chemical peel

Dermabrasion

Laser resurfacing

Injectable Idlers

Other Abdominoplasty

Call augmentation

Liposuction r "i

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Gender-Affirming Surgery (Transition-Related

Surgery)

• ensure appropriate use ofgender pronouns

• some procedures require I vr trial ofhormone therapy,preoperative letters of evaluation and

documentation from mental health professionals as outlined by the World Professional Association

for Transgender Health Standards ofCare - Version 7 guidelines

Table 33. Surgical Options for Transgender Women

Procedure Description Follow-Up

Surveillance for implantrupture

Adhere to breast cancer screening guidelines in addition

to gender-specific medical maintenance

Short-term restrictions on placing body weight on fatgrafted areas (*2 wk)

100% of injected fal volume nol maintained long- term

Breast Augmentation Implant-based,fat-grafting, or combined surgery to

increase breast sire

Contouring Procedures Altering fal distribution in distinguishing regions ol

the body (abdomen, flank, hip, and bullock) using

liposuction oi fal grafting (limited by availability ol

autologous fal)

t Hairline suigery

iForehead augmentation or osteotomy

t Rhinoplasty

± Genioplasty (implant alone is usually not sufficient)

Cartilage removal to reduce thyroid cartilage size

Facial Feminization Hair transplant may be needed in adjunct

May have altered lip sensation and altered sensation of

lower incisors with genioplasty

Chondrolaryngoplasty Risk of long-term hoarseness based on anatomical

proximity of recurrent laryngeal nerve to site of surgery

Nol all procedures are permanent (i.e.cricothyroid

approximation)

Some procedures may narrow air way (i.e. anterior glottal

web formation)

Nol guaranteed to achieve exact desired pitch change

Vocal Cord Surgery Alteration ol vocal cordlength to increase vocal pitch

Vaginoplasty see Urology. Itanution-Relati

'dSurgeries , fable 26. U47

Table 34. Surgical Options for Transgender Men

Procedure Description Follow-Up

Chest Masculinization Most common technique is double incision free nipple Loss of nipple sensation

graft technique

May need liposuction for patients with excess

subcutaneous tissue

Contouring Procedures

Facial Masculinizalion

see fob/e 33

t Forehead augmentation

* Maxillary augmentation

i Mandibular augmentation

tRhinoplasty

t Genioplasty

Cartilage added to increase thyroid cartilage Risk of vocal cord paralysis due to surgery

prominence

Alteration ol vocal cord length to decrease vocalpitch Nol guaranteed lo achieve exact desired pitch change

Phalloplasty, Metoidioplasty see Urology, hansilion Rclolcd Suigeiia. table 26. U47

May have altered lip sensation and altered sensation of

lower incisors with genioplasty

Thyroid Cartilage

Enhancement

VocalCord Surgery

• for further information on gender-affirming surgical techniques,see Urology, Transition-Related

Surgeries, U47

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Paediatric Plastic Surgery

Craniofacial Anomalies

Table 35. Paediatric Craniofacial Anomalies

Definition Epidemiology Clinical Features Treatment

Cleft Lip Failure of fusion of

maxillary and medial

nasal processes

1in 1000 live births

(increased incidence

in Asian individuals,

decreased incidencein

individuals of African

descent)

Isolated cleft palate:0.5 in Classified as incomplete/ Special bottles for feeding

1000 (no racial variation) complete and unilateral/ SIP

bilateral

4% chance oldellIIone Isolated (commonIn

parent or sibling have dell females) or in conjunction 2-Plasty

17% chance of cleft if with deft lip (common in ENT consult- often recurrent otitis

both sibling and parent males)

have deft

tin 2000 live newborns:

M:E-52:48

Syndromes include:

Crouzon's,Apert's.

Saelhre-Chotzen,

Carpenter's.Pfeiffer’s.

JacksonWeiss.and

Boston- type syndromes

Classified as incomplete/ Surgery (3 mo):Millard,or Fisher

complete and unilateral/ (additional corrective surgeries

bilateral:2/3 cases: usually required later on •

unilateral,left-sided,male especially lor nasal deformity

Failure of fusion of

lateral palatine/median

palatine processes and

nasal septum

Cleft Palate

Surgery (6-9 mo):

Von langenbeckor Follow

F -M

media,requiring myringotomy

tubes

Craniosynoslosis Primary (no known cause). Multidisciplinary learn (including

or secondary (associated neurosurgery.ENf.genetics,

with a known cause or dentistry,paediatrics.SLP)

syndrome) the type,timing,and procedure

are dependent on which sutures

(lambdoid,sagittal,etc.) are

involved

Early surgery prevents secondary

deformities

Congenital Hand Anomalies

Table 36. American Society for Surgery of the Hand (ASSH) Classification of Congenital Hand

Anomalies

Classification Example Features Treatment

Failure olFormation Transverse absence Atanylevel (oflenbelowelbow/

(congenital amputation) wrist)

longitudinal absence

(pliocomelia)

Early prosthesis

Absent humerus

lhalidomide association Figure 38. Veau classification of cleft

lip and palate

Image reproduced with permission from

Medscape Drugs £Diseases

(https://ernedicinejriedscape.com'

'

).Cleft Lip and

Palate andMouth and Pharynx Deformities,2021.

available at:https://eniedkine.medscape.com/

altide/837347.overview

Radial deficiency (radial Radial deviation

club hand)

Physiotherapy'

splinting

Soft tissue release if splinting fails

Distraction osteogenesis (Ilizarov distraction)

wedge osteotomy

tendon transfer

Pollicitation

Depends on degree - may involve no treatment,

webspace deepening,tendon transfer,or pollicization

of index finger

Thumb hypoplasia

M»F

thumb hypoplasia Syndromes include:Fanconi

anemia. Holt-Ogram.and CHARGE

syndromes.Degree ranges from

small thumb with alt components to

complete absence

Ulnar club hand Rare,compared to radial club band Splinting and soft tissue stietching therapies

Stable wrist Soft tissue release (if above fails)

Correction of angulation (Ilizarov distraction)

Clell hand First web space syndactyly release

Osteotomy/tendon transfer of thumb (if hypoplastic)

Autosomal dominant

Olten functionally normal

(depending on degree)

Failure of

Differentiation/

Separation

Syndactyly Syndromes include:Apert,Poland,

and HollOram syndromes

1in 3000 live births

M:F-2:1

Short lingers with sborlnails at

Fingertips

Congenita!flexion conlracture Early splinting

(usually at PIP.especially 5th digit) Volat release

Arthroplasty (rarely)

Surgical separation before 6-12 moot age

May require a skin graft to cover the Angers

Usually good result

r T

L J Symbracbydactyly Digital separation

Webspace deepening

Camptodactyly

+