The field of plastic and reconstructive surgery is concerned with the reconstruction or improvement of the form and function of many areas of the body. Rarely can either form or function be sacrificed for the other, but one is often of greater concern. This chapter concentrates on reconstructive surgery that is required because of abnormalities of the skin and soft tissues. These abnormalities may be caused by trauma, malignancies, congenital deformities, or other diseases.

Because plastic surgery almost always involves the skin, this chapter begins with a review of the structure of the skin, the process of wound healing, and the reconstruction of large defects. (For a more complete discussion of wound healing, see Chapter 8 in Lawrence et al., Essentials of General Surgery. 4th ed.) These discussions are followed by sections on benign skin lesions, facial trauma, hand surgery, congenital deformities, acquired deformities, and, finally, aesthetic surgery. This type of surgery differs from reconstructive surgery because it is directed at the cosmetic improvement of normal structures.

SKIN STRUCTURE

The skin, or integument, is the largest organ of the body and completely envelops its surface. The skin is both the primary defense against the environment and the principal means of communicating with it. The skin also serves important functions in terms of homeostasis and thermoregulation. The integument is an indispensable organ: total destruction of the skin is incompatible with life.

The skin is divided into two embryologically distinct layers: the epidermis and the underlying dermis (Fig. 3-1). The epidermis has five distinct strata, the cells of which all derive from the innermost of these strata, the stratum germinativum, or basal layer. Mitosis of this layer, with transformation of these cells as they migrate outward, forms the other strata of the epidermis. Located within the basal layer are the pigment-containing melanocytes. The epidermis is devoid of vasculature and receives its nourishment from the underlying dermis. Epidermal projections known as rete pegs extend down into the underlying dermis.

Figure 3-1   Cross-section anatomy of the skin.

The dermis is 15 to 40 times thicker than the epidermis. It is divided into the thin papillary dermis, located beneath the epidermal rete pegs, and the thicker subjacent reticular dermis. The papillary dermis contains reticular and elastic fibers intermingled with a rich capillary network. The reticular dermis contains dense bundles of collagen parallel to the surface of the skin. This layer provides much of the tensile strength of the skin. Also contained within the dermis are pilosebaceous apparatus, eccrine and apocrine units, and important nerve end organs (e.g., pacinian and Meissner’s corpuscles).

WOUND HEALING

Wound healing has three phases. The initial (inflammatory) phase is characterized by inflammation around the edges of the wound, a nonspecific reaction to any injury. Leukocytes remove debris and bacteria. Toward the end of this relatively brief phase, activated macrophages appear and direct the next phase. The inflammatory phase lasts approximately 4 days in wounds with little contamination, but may be significantly prolonged in contaminated wounds. The second (proliferative) phase is characterized by collagen production by fibroblasts. Tissue fibroblasts synthesize collagen at an increased rate for approximately 6 weeks in normal wound healing. This synthesis causes a rapid gain in wound tensile strength that peaks at the end of this phase (Fig. 3-2). The third (maturation) phase consists of the remodeling of collagen by the formation of intermolecular cross links. This phase, which lasts 6 to 18 months, leads to a flatter, paler scar, with little increase in tensile strength through a dynamic balance of collagenolysis and collagen synthesis.

Figure 3-2   Wound tensile strength as a function of days.

Wound healing is classified as healing by primary, secondary, or tertiary (delayed primary) intention. Healing by primary intention involves recent, clean wounds that are managed by suture repair. These wounds are first gently irrigated and debrided to minimize the inflammatory process. Debridement consists of removing foreign material and devitalized tissue. After debridement, the tissue planes are approximated accurately to provide optimal healing. At the peak of collagen synthesis, the scar is mildly inflamed. It is raised, red, and often pruritic. Over time, the scar flattens, thins, and becomes much lighter. The process takes at least 9 to 12 months in an adult and somewhat longer in a child. The final appearance of a scar depends on the initial injury, the amount of contamination and ischemia, and the method and accuracy with which the wound was closed. Wound healing is delayed by multiple factors, including impaired circulation, immunosuppression, infection, or inadequate nutrition. Absorbable sutures are usually used below the skin surface. Nonabsorbable sutures are used for the outer closure because they are less reactive (Fig. 3-3).

Figure 3-3   Techniques of skin closure. A, Simple interrupted sutures. B, Vertical mattress sutures. C, Running intracuticular (subcuticular) sutures. D, Continuous simple sutures.

Wounds that are left open to heal without surgical intervention heal by secondary intention. This secondary closure is characterized by a prolonged inflammatory phase that persists until the wound is covered with epithelium. Wounds treated in this manner eventually heal, unless factors such as infection and foreign bodies are present. Epithelialization from the wound margins proceeds at approximately 1 mm/day in a concentric pattern. Wound contraction greatly reduces the size of the wound, although it never approaches the final appearance of a primarily closed wound. Healing by secondary intention is indicated in infected or severely contaminated wounds because abscess or wound infection rarely develop in an open wound.

Delayed primary closure, or healing by tertiary intention, involves the subsequent repair of a wound that was initially left open or was not repaired. This method is indicated for wounds with a high (>10 ) bacterial content (e.g., human bite), a long time lapse since initial injury, or a severe crush component with significant tissue devitalization. Successful closure depends on the cleanliness of the wound, preparedness of the wound edges, and absence of significant bacterial colonization (<10 bacteria/g tissue).

Abnormal healing may take the form of hypertrophic scars or keloids. Hypertrophic scars are raised, widened, and red. They may be pruritic, with tissue remaining within the boundaries of the scar (Fig. 3-4A). Keloids have an abnormal growth of tissue that usually mushrooms over the edges of the wound and extends outside the boundaries of the scar (Fig. 3-4B). Keloids are more common in African Americans and Asians. Differentiating between the two scars is important because their treatment differs. A hypertrophic scar often improves with time or may be improved by surgical revision. A keloid may be made worse by revision and is treated with intralesional steroids, external pressure, radiation, or a combination of modalities. (For further discussion of wound healing, see Lawrence et al, Essentials of General Surgery. 4th ed., Chapter 8, Wounds and Wound Healing.)

Suture Material

Suture material, suture placement, and knot-tying are fundamental elements to a successful surgical outcome. Understanding the properties of suture material and becoming proficient in knot-tying are critical skills for most physicians, not just surgeons. Properly tying sutures requires a great deal of practice. (A review of the various suture materials is provided in Chapter 8 in Lawrence’s Essentials of General Surgery, 4th ed, Wounds and Wound Healing, Table 8-4, Suture Material.)

Figure 3-4   A, Hypertrophy of a scar on the volar wrist. The scar does not extend beyond the boundaries of the original scar. B, Keloid of a scar of the helical rim. The scar tissue mushrooms out beyond the boundaries of the original scar.

Types of Wounds and Their Treatment

Different wounds have specific causes and treatment guidelines.

Lacerations

Lacerations consist of cut or torn tissue. Care includes gentle handling of tissues. In addition, the wound should be cleansed of clots, foreign material, or necrotic tissue and irrigated with a physiologic solution (e.g., saline, lactated Ringer’s solution). Administering a local anesthetic before the final cleansing is helpful. Once cleansed, lacerations are closed with an atraumatic technique, with care taken not to further crush or injure the tissues. Careful closure of wound margins gives the best chance for ideal healing with minimal scarring (Fig. 3-5). Dressings should consist of sterile material that will protect the wound and absorb some wound drainage. Immobilization is helpful in complex extremity wounds.

Figure 3-5   Complex laceration of the forehead and eyelid. A, Before debridement and closure. B, After debridement and closure.

Abrasions

Abrasions are injuries in which the superficial skin layer is removed. They may be of variable depth. Abrasions should be gently cleansed of any foreign material. Occasionally, more vigorous rubbing with a scrub brush is appropriate. A local anesthetic can facilitate cleansing. Dirt and gravel are removed to prevent permanent discoloration (traumatic tattooing). The wound must be cleansed within the first day after injury. After this cleansing, an abrasion can be cared for by any method that keeps it clean and moist. The use of topical antibiotic ointment or protective dressings is appropriate.

Contusions

A contusion is an injury that is caused by a forceful blow to the skin and soft tissues. The entire outer layer of skin is intact, although it is injured. Contusions require minimal early care. They should be evaluated early to diagnose a possible deep hematoma or tissue injury. Large or expanding hematomas may require evacuation, particularly if, through pressure, they threaten the viability of the overlying skin, cause vascular or neurologic compromise, or cause airway obstruction.

Avulsions

Avulsions are injuries in which tissue is torn off, either partially or totally. In partial avulsions, the tissue is elevated but still attached to the body. If this raised portion of tissue is adequately vascularized and appears viable, it is gently cleansed, irrigated, replaced into its anatomic location, and anchored with a few sutures. If the tissue is not viable but is still attached, the best approach is usually to excise the tissue and use an alternative method of closure (e.g., skin graft, local flap; discussed later). Completely avulsed tissue usually cannot be directly replaced as a graft because it is too thick to permit reliable healing. In some cases, the skin is debulked, defatted, and used as a skin graft.

Major avulsions (e.g., amputation of extremities, fingers, ears, nose, scalp, eyelids) require specialty evaluation and care. Because replantation of some avulsed tissue is possible if it is handled appropriately, a replant team should be consulted promptly. For appropriate tissue preservation techniques, see the discussion of amputations.

Bites

Bites from animals and humans are a major problem because they are heavily contaminated by bacteria. Although dog bites may be appropriately left open for wound care, most, if handled appropriately, can be closed and heal without infection. Because of their much heavier bacterial contamination, however, human bites should be irrigated, debrided, and left open. In sensitive areas such as the face, thorough debridement and attempted closure may be appropriate. Broad-spectrum antibiotics should also be administered. Human bites to the hand are a special topic and are discussed later. Immobilization and elevation of extremity wounds aid in the healing of these heavily contaminated wounds.

Contaminated Wounds

A contaminated wound is one that has been exposed to bacteria from the body or local environment. The management of acute, significantly contaminated wounds consists of debridement, irrigation, and healing by secondary or tertiary intention. The use of antibiotics is reserved for severely contaminated wounds, wounds in immunocompromised patients, contaminated wounds that involve deeper structures (e.g., joints, fractures), and obvious infection. The choice of antibiotic depends on the most likely organisms given the cause of the injury. Broad-spectrum antibiotics with coverage of Staphylococcus aureus are usually recommended. Contaminated wounds are closed cautiously, depending on the degree of contamination and the location of the wound. Deep sutures should be kept to a minimum and should be monofilament. Patients with contaminated wounds are reevaluated within 24 to 48 hours. If any signs of deep infection are seen on reevaluation, at least a portion of the wound is opened by removing the sutures.

Contaminated Chronic Wounds

Lacerations and open injuries that are older than 24 hours require debridement and irrigation. With few exceptions, systemic antibiotics are not helpful in controlling bacterial colonization within a contaminated chronic wound. Antibiotic penetration into a chronic wound, with its granulating fibrous bed, is poor and unpredictable. Topical antibiotic cream (e.g., silver sulfadiazine [Silvadene], bacitracin, Neosporin) may be helpful in areas of partial-thickness skin loss. However, some of these topical agents inhibit epithelialization and the initial aspects of wound healing. Highly toxic solutions (e.g., alcohol, hydrogen peroxide) may adversely affect wound healing by destroying normal tissue. Contaminated wounds should be closed only after bacterial contamination is controlled. Chronic wounds that show no evidence of epithelialization or contraction or that are any color but the beefy red of a granulating bed usually have significant bacterial contamination and may be clinically infected. Although the type of organism is important, the principal determinant of wound sepsis seems to be the total bacterial load per gram of tissue (> 10 bacteria/g tissue). Proteinaceous and necrotic debris may also be treated with enzymatic (e.g., collagenase, papain, and urea) as well as surgical debridement.

Wound Management

The initial care of the wound is a major determinant in healing. Methodical assessment of the injury, followed by meticulous closure, minimizes deformity and maximizes the functional result. Evaluation includes an assessment of tissue injury, amount of tissue lost, and degree of injury to deeper structures. Treatment of a wound begins after the patient is evaluated and stabilized. After careful debridement and hemostasis, the injury pattern and tissue deficit are defined before the appropriate reconstructive technique is selected. Bleeding within the wound is controlled by direct pressure. Random clamping of tissue with hemostats should be avoided because it can crush normal tissue or injure other structures (e.g., nerves). Because a tourniquet can increase venous bleeding or cause limb ischemia, it is used only to control life-threatening hemorrhage that cannot be controlled by other means. After bleeding is controlled, the wound is gently irrigated with a physiologic solution (e.g., normal saline).

After the wound is cleaned, the viability of the wound margins is assessed. Clean lacerations have minimal surrounding tissue injury. Contused, contaminated wounds have a crush component of surrounding ischemic tissue. In general, recent, clean wounds without tissue loss can be gently irrigated and closed. However, crushed, contaminated wounds have areas of tissue injury and devitalization that may require debridement and closure, delayed closure, or even the use of skin grafts or flaps to resurface injured areas that have inadequate overlying tissue. Specialized tissues (e.g., eyebrows, eyelids, ears, lips) and other tissues that are difficult to replace precisely should be debrided only by a physician experienced in complicated wound care. Some areas of the body (e.g., face) have a rich vascular supply and tend to heal well. However, the viability of portions of these wounds initially may be in question. As a rule, any questionable tissue should be gently irrigated and reexamined 24 to 48 hours later. Although contused, crushed injuries predictably have a less favorable outcome, precise reconstruction can optimize the results.

A recent adjunct to wound management has been a vacuum-assisted closure device (V.A.C., Kinetic Concepts, Inc., San Antonio, TX). This device consists of a sponge that is placed in the wound bed, which is then sealed with a dressing and connected to suction. The ability to prescribe negative pressure wound therapy provides multiple benefits for wound management and closure. The V.A.C. system will assist in promotion of granulation tissue formation, aid in removal of interstitial fluid, and uniformly draw wound edges closer together through the use of the controlled, localized negative pressure.

For all penetrating injuries and many nonpenetrating injuries (e.g., abrasions, burns), the patient’s tetanus immunization status must be determined. Guidelines for wounds that may be tetanus-prone should be followed (Table 3-1).

RECONSTRUCTION OF LARGE WOUNDS AND TISSUE DEFECTS

Wounds that cannot be repaired by simple approximation of the wound margins often require an alternative method of reconstruction (e.g., graft, flap). When choosing the appropriate method of reconstruction, the concept of a “reconstructive ladder” must be kept in mind (Fig. 3-6). This ladder is a classification of the methods of wound reconstruction in order of increasing complexity. Simpler methods are often best, but they do not always suffice. The different “rungs” of the ladder are discussed in this section (direct closure, where appropriate, was discussed previously under Types of Wounds and Their Management, Lacerations).

Figure 3-6   The reconstructive ladder.

Skin Grafts

A skin graft is a portion of the skin (including the epidermis and a variable amount of dermis) that is completely removed from its original location (donor site) and transferred to another area of the body (recipient site). No underlying tissue is included. Because of its separation, a skin graft derives all of its nutritional supply from its recipient bed. It carries neither vasculature nor any lymphatic or nerve structures. Skin grafts are categorized according to species and thickness.

Species Classification

An autograft is a graft taken from one place on an individual and transplanted to another place on the same individual. Immunologic compatibility is ensured, and the graft is considered permanent. An allograft (homograft) is a graft taken from one individual (usually a cadaver) and transplanted to another individual of the same species. These grafts are useful for temporarily resurfacing defects. Rejection eventually occurs, except in cases of transplantation between identical twins or, potentially, in people who are permanently immunosuppressed. The third type of species graft, a xenograft (heterograft), is a graft from a donor of one species to a recipient of a different species. This type of graft, commonly used in clinical practice, entails the use of porcine skin to cover large skin and soft tissue defects on a temporary basis. A variety of new synthetic bilaminar products (e.g., Biobrane, Berthek Pharmaceuticals, Morgantown, WV, or Transcyte, Smith and Nephew, La Jolla, CA) has been developed to assist in coverage of wounds. Although their long-term stability is less than that of auto-grafts, they can serve a significant role for early wound coverage

Thickness Classification

A split-thickness skin graft includes the epidermis and a portion of the dermis (Fig. 3-7). The graft includes a variable number of dermal appendages, depending on the thickness of the dermis taken with the graft. The success of the skin graft increases with thinner grafts because less vascular ingrowth is required to maintain their viability. Thinner grafts can also be expanded to a greater degree than thicker grafts. They are used in areas of large skin loss (Fig. 3-8), over areas of granulating tissue, and in areas of marginal vascularity or potential contamination. These grafts are harvested with an air- or electric-powered dermatome or a specialized freehand knife. The donor site, which represents a partial-thickness loss, heals by reepithelialization from wound edges and from residual deeper skin dermal appendages scattered throughout the wound base. The donor site requires ongoing care to prevent secondary infection, which can create full-thickness loss. This care consists of keeping the wound moist while minimizing contamination, pressure, and desiccation. Split-thickness skin grafts are usually taken from the buttock or high thigh area because of the large amount of surface area available and the relatively inconspicuous location. Split-thickness skin grafts have an added benefit in that they can easily be “meshed” with an opertive device at various ratios (e.g., 2:1, 3:1, 4:1). This allows for gentle separtaion of the meshed tissue for greater surface area coverage.

Figure 3-7   Different levels of thickness of skin grafts.

Figure 3-8   Open wound of the forearm. A, Before split-thickness skin grafting. B, After successful healing of a meshed graft.

A full-thickness skin graft consists of the epidermal layer and the entire thickness of the dermis (Fig. 3-7). In contrast to a split-thickness graft, it provides a more durable form of coverage, its appearance is more normal, and it carries an increased number of dermal appendages. However, because of its greater thickness and slower revascularization, it may be less likely to succeed than a split-thickness skin graft. The absolute thickness may vary according to the thickness of the dermis at the donor site. A thin full-thickness skin graft may be obtained from the eyelid or postauricular areas. Thicker full-thickness skin grafts can be obtained from the cervical and groin areas. Full-thickness grafts are usually used on the face because of their better color match, on the fingers to avoid joint contractures, and at any site where thicker skin or less secondary contraction is desired. Because the donor site is a full-thickness defect, it is managed by either primary closure or split-thickness skin grafting. This factor limits the size of full-thickness skin grafts. These grafts are usually taken from the groin, postauricular area, upper eyelid, supraclavicular area, or scalp. The last four locations are useful for reconstruction in the head and neck because of proper color match, but a limited amount of skin is available (Fig. 3-9).

Figure 3-9   Comparison of split-thickness and full-thickness skin grafts.

When a graft is harvested, it contracts immediately after it is freed from the surrounding tissue. This primary skin graft contraction is related to the number of elastin fibers in the graft. Thus, the thicker the graft (because of the greater number of elastin fibers it contains), the greater the primary contraction.

Secondary contraction occurs during the healing phase (Fig. 3-9). As healing occurs, the graft contracts to leave a smaller surface area. The thicker the graft, the less secondary contraction occurs. This phenomenon is more closely related to the percentage of dermis in the graft than to the actual thickness. Consequently, a graft that includes 50% of the dermis would be predicted to contract less than a graft that contains 30%. Secondary contraction is mediated by myofibroblasts (specialized fibroblast-like cells that contain smooth muscle contractile elements) within the wound. The dermis suppresses the myofibroblast population. Greater suppression is seen with greater thickness of the dermis.

Contraction must be taken into account when planning reconstruction. Thus, reconstruction of defects or scar contractures may need more graft placed than initially predicted. On the other hand, secondary graft contraction may be used to provide an advantage. A large defect can be surfaced with a thin split-thickness skin graft with the expectation that the total surface area will shrink with the skin graft contraction. A secondary procedure can be performed to excise a portion of the defect and leave a much smaller defect.

Skin Graft Healing

Because the skin graft is completely isolated from its original nutrient source when it is harvested, it must survive initially by diffusion of oxygen and nutrients from the recipient bed. The diffusion of nutritional elements and fluid from the recipient site and the subsequent diffusion back to the host bed of metabolic waste products is called plasmatic imbibition. This process allows the skin graft to survive for the first 48 to 72 hours after placement. Vascular ingrowth begins shortly after the skin graft is placed on the host bed. However, adequate nutritional exchange to maintain tissue viability does not occur until 48 to 72 hours after graft placement. The new ingrowth of capillary tissue into the graft (neovascularization) is known as inosculation. The recipient bed is prepared by minimizing the bacterial concentration and removing poorly vascularized tissue. Wounds may require debridement at grafting or even several days before grafting. An adequate vascular supply must be ensured, particularly in the compromised extremity. Physical examination is usually sufficient, but Doppler examination or arteriography may be necessary. If local blood flow is inadequate, vascular bypass or another procedure may be necessary. A well-vascularized recipient site, if kept clean, shows signs of local capillary proliferation. The mixture of capillary buds and connective tissue (granulation tissue) is usually beefy red and bleeds easily to touch. In most cases, it forms a good recipient bed for skin grafting, but because it is a chronic open wound, it also supports bacterial growth.

The graft should be immobilized on the recipient site to prevent shear forces from dislodging the tenuous ingrowth of new capillaries. Separation of the graft from its bed prevents both the diffusion of nutrients and the ingrowth of new vascular tissue, resulting in loss of the skin graft. Because skin grafts require a well-vascularized recipient bed, they do not take on relatively avascular structures (e.g., bone, tendon, heavily irradiated areas, infected wounds). However, skin grafts take well on periosteum, paratenon, and perichondrium.

Graft failure is usually caused by mechanical blockage of diffusion (e.g., hematoma or seroma under the graft), shearing forces that dislodge the graft from its recipient bed, or an inadequate recipient site (because of contamination or poor blood supply). Systemic factors (e.g., malnutrition, sepsis, medications) may also play a role in the success of the skin graft. Systemic steroids, antineoplastic agents, and vasoconstrictors (e.g., nicotine) may adversely affect skin graft survival and wound healing in general.

Flaps

Tissues that are transferred from one location to another and are supported by an intact blood supply are commonly known as flaps. They are typically used to replace tissue that is lost because of trauma or surgical excision. Flaps provide temporary or permanent skin coverage in critical areas that require good soft tissue bulk for underlying structures (e.g., tendons, joints). They also may provide increased padding over bony prominences (e.g., pressure sore reconstruction). They bring a better blood supply to relatively poorly vascularized areas and are occasionally used to improve sensation to an area by bringing in an accompanying nerve supply. In addition, they are used to carry specialized reconstructive tissue (e.g., bone, cartilage). Flaps may consist of skin, subcutaneous tissue, muscle, bone, cartilage, nerve, and such specialized tissues as jejunum, omentum, or fascia. Skin flaps are classified according to their vascular anatomy as random or axial and according to their anatomic location as local, regional, or distant.

A random-pattern skin flap is an area of skin and subcutaneous tissue that has no specifically defined vascular distribution (Fig. 3-10). For viability, the flap depends mostly on the random dermal and subdermal plexus of vascular structures. It has a limited length-to-width ratio to ensure that enough blood vessels are included to provide nutrition throughout its length. Random flaps may be raised in any location, assuming normal vascularity of the skin.

Figure 3-10   A, Patient with a dermatofibrosarcoma protuberans of the left lower eyelid and cheek. B, After radical resection. C, After coverage with a random-pattern skin flap of adjacent cheek and neck skin. The length-to-width ratio of the flap is approximately 1:1.

A Z-plasty is a specific use of random-pattern skin flaps. It involves raising two random flaps in a Z-shape. The flaps are interpolated and then interdigitated with one another (Fig. 3-11). In so doing, two things are accomplished. First, the scar is lengthened at the expense of width. Second, the direction of the scar is reoriented. Z-plasties are often used when scar contractures have developed. Varying the angle of the Z will vary the amount of lengthening of the skin. The normal angles are usually 60 and 120 degrees.

Figure 3-11   A Z-plasty is used to reorient and lengthen a scar (distance a to b) at the expense of width.

Axial-pattern, or arterialized, flaps differ from random-pattern flaps because they are based on a named blood supply (Fig. 3-12). The underlying vasculature must be well mapped, and the flap outline must be designed to maximize the vascular supply. The vascular supply must include a direct artery and accompanying veins. Specific axial-pattern skin flaps in different anatomic locations take advantage of known cutaneous arteries. Because of this known arterial supply, a greater length-to-width ratio (up to 5:1 or 6:1) is usually possible than with the random flap. Some axial flaps may be used as free flaps (see later discussion).

Figure 3-12   A, Open wound of the antecubital fossa. B, A thoracoepigastric axial-pattern skin flap is designed. Its length greatly exceeds its width. C, The flap is attached as a pedicled flap and left for several weeks before the pedicle is divided. D, After the pedicle is divided, is inset, and has healed.

Tissue expansion is a comparatively new technique that uses the ability of skin to relax and expand as a result of tension applied to it. When local tissue directly adjacent to the wound is the best option for reconstruction (e.g., scalp defects), the two-stage process of tissue expansion is used. An inflatable prosthesis is placed beneath the skin or other tissue to be expanded. After initial healing occurs, the expander is serially inflated through a valve or injection port, usually weekly. When full expansion is achieved, the expander is removed at a second operation. The expanded tissue is used as a local flap to reconstruct the wound (Fig. 3-13).

Figure 3-13   A, A young patient with a large sebaceous nevus of the scalp. B, A tissue expander is placed anteriorly and fully inflated. C, Result after resection of the lesion and coverage with the expanded scalp skin.

Composite Flaps

Composite flaps offer another technique for reconstruction. In this technique, multiple tissue types such as skin, fascia, and bone are transferred to allow closure of critical defects with materials similar to those that were lost.

Myocutaneous flaps are the next most complex type of flaps used for reconstruction (Fig. 3-14). The skin overlying many muscles of the body is supported by vessels that course directly from the muscle to the skin (musculocutaneous perforators). Large amounts of skin left attached to the underlying muscle can be transferred from one location to another as long as the blood supply to the underlying muscle is preserved. Knowledge of the blood supply to these muscles allows rotation or transposition of the tissue from the donor site to the reconstructed wound. The location of the dominant vasculature is used as the pivot point for the arc of rotation. In some cases, a muscle alone is transferred and subsequent skin grafting is performed.

Figure 3-14   A, A patient who had a point-blank shotgun blast to the chest. B, The defect is closed with a latissimus dorsi myocutaneous flap. C, Once the flap is elevated, it is tunneled into the defect on the chest. D, The patient after D successful reconstruction.

Fasciocutaneous flaps can also be used for coverage. These flaps are similar to myocutaneous flaps, except that the blood suppy to the skin does not course through muscle. Consequently, these flaps provide thin and well-vascularized coverage from a named artery to assist in covering defects.

Flaps Used in Microvascular Surgery

Free flaps raised from a distant site may be used if local skin flaps or regional myocutaneous flaps are not available for wound reconstruction. These flaps are transplanted from one site of the body to another by isolating the dominant artery and veins to a flap and performing a microscopic anastomosis between these and the vessels in or near the recipient wound. Muscle and skin are most commonly used, although bone, nerves, tendons, jejunum, and omentum may also be transferred. Although these flaps may be used in almost any reconstruction situation, they are predominantly used in lower extremity, breast, and head and neck reconstructions (Fig. 3-15).

Figure 3-15   A, A close-range shotgun blast to the ankle required external fixation of the ankle and vascular reconstruction. B, The ankle immediately after reconstruction with a free muscle flap and a skin graft. C, Long-term result showing satisfactory reconstruction.

MANAGEMENT OF BENIGN SKIN LESIONS

Types of Lesions

Skin lesions are either benign or malignant. Differentiation is important in providing appropriate care. Common benign lesions include the nevus, keratosis, verruca, fibroma, and hemangioma. Common malignant lesions include basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. (Malignant lesions are discussed in Chapter 25 in Lawrence’s Essentials of General Surgery, 4th ed.)

The nevus is the most common lesion in the adult. It is usually brown and slightly raised, and it may have hair (Fig. 3-16). Nevi are subclassified according to the appearance and depth of active proliferating cells. Dysplastic nevi have the potential for malignant transformation. They have irregular borders and varying shades of pigmentation. It is impractical to excise all nevi, but suspicious pigmented lesions that have had a recent change in size, elevation, color (brown to black or gray), or irregular borders (notching) should be excised. In addition, lesions that have a surface discharge, a tingling sensation, bleeding, or itching and those that are constantly irritated (e.g., those under a belt line or bra) should be excised. All significant nevi should be carefully observed.

Figure 3-16   Benign nevus.

The second most common type of benign lesion is keratosis. It is subclassified into seborrheic keratoses, actinic keratoses, and keratoacanthomas. A seborrheic keratosis is elevated, brown, and has a greasy feeling. It usually has a “stuck-on” appearance and can be treated by freezing, scraping, cauterizing, or excision. If the diagnosis is uncertain, it should be excised. An actinic keratosis is a rough, irregularly shaped, brownish patch, most commonly seen in the elderly. Because these keratoses may be premalignant, some may be removed at the discretion of the surgeon and patient. A keratoacanthoma is a rapidly growing, elevated lesion that may have a central crater or ulceration (Fig. 3-17). It usually resolves spontaneously in 4 to 6 months; however, concern over its growth and appearance often justifies excision for diagnosis.

Figure 3-17   Keratoacanthoma of the hand, with a central crater or ulcer.

A verruca (wart) usually has a viral etiology. It is characteristically self-limiting. Spontaneous disappearance after several years is the rule. Surgical excision is occasionally indicated, especially if the lesion occurs on pressure points and is symptomatic (e.g., soles of feet, palms of hands). However, these lesions are usually removed with cryosurgery or laser vaporization. Persistently enlarging lesions may suggest verrucous carcinoma and require surgical excision.

Fibromas are solid lesions. They occur just below the skin surface and may involve skin structures. They are subclassified into fibromas, neurofibromas, and dermatofibromas. Large or symptomatic fibromas should be removed.

Hemangioma is the most common benign tumor of infancy. It consists of an abnormal collection of blood vessels. Several classifications exist based on the likelihood of proliferation or regression. Treatment consists of observation unless these tumors become physiologically or functionally important (e.g., causing visual or airway obstruction, bleeding, or ulceration).

Vascular malformations are the other classification of pigmented congenital lesions. They tend to grow with the child, with no regression being seen. A variety of options exists for these lesions, including laser therapy, embolization, and surgical excision.

Techniques for Excision

In excising small skin lesions or subcutaneous lesions, the goal is to completely remove the lesion while leaving as inconspicuous a scar as possible. Although the surgical technique significantly affects the final appearance of the scar, other factors (e.g., location, size, and orientation of the lesion; overall health; age) also influence the result. A spindle-shaped, or lenticular, incision is made. The total length of the spindle is approximately twice the diameter of the lesion. The long axis of the incision should parallel lines of relaxed skin tension. The incision is made distinctly into the subcutaneous tissue, but should not penetrate into the fascia or deeper structures. Gentle undermining can help decrease tension on the closure. Careful layered closure provides the best result. The specimen should always be sent to the pathologist, even when it appears to be benign.

FACIAL TRAUMA

The patient with facial injuries requires early wound care; accurate diagnosis by history, physical examination, and radiographic studies; and appropriate wound repair and fracture stabilization. Facial fractures should be reduced and stabilized within the first 5 to 7 days. If the patient’s condition allows it and evaluation of the facial injuries is complete, early repair is preferable.

If the patient has other significant injuries (e.g., closed head, intrathoracic, cervical spine, or intra-abdominal injuries), medical attention to these injuries takes priority over repair of the facial fractures. However, fixation of facial fracture can be combined with neurosurgical, orthopedic, or other procedures without increased morbidity. This approach allows early or immediate repair of the facial injuries, diminishing the effects of soft tissue contraction, potential infection, and scarring. Secondary revision of facial injuries may be required, but should be delayed until scars mature and fractures heal (6–12 months). Occasionally, skin grafts and flaps are required for large soft tissue defects.

Emergency Care

The initial care of the patient with facial injuries focuses on managing the airway and controlling bleeding. Foreign material and blood are removed from the airway either by hand or by suction. Tracheostomy is seldom indicated when the injury involves only the facial soft tissues. However, for facial fractures, bleeding, and potential cervical spine injuries, cricothyroidotomy or early tracheostomy may be appropriate. After the airway is clear and adequate ventilation is established, bleeding should be controlled. Direct pressure is usually adequate. Dressings wrapped around the face rarely ensure prolonged control of bleeding. Vessels should not be clamped until the injury is adequately visualized because blind clamping can injure important structures (e.g., facial nerve).

After the extent of injury is assessed, the wound is carefully cleansed. All foreign material should be carefully removed. The wound is also palpated or gently explored to detect underlying injury to bony structures. Manual physical examination is the most sensitive means of detecting facial fractures. After initial wound care and hemostasis, the underlying structures can be repaired.

Soft Tissue Defects

As soon as the patient’s general condition allows, soft tissue injuries are treated. Ideally, treatment occurs within the first several hours after injury. If the patient’s general condition is not good, primary wound closure may be delayed. Because of the excellent vascular supply of the face, facial wounds can be closed up to 24 hours after injury if necessary.

Soft tissue repair of the face requires gentle cleansing, minimal debridement, and restoration of all available parts. Most injuries cause little or no tissue loss once they are evaluated. The illusion of skin loss is the result of skin elasticity and retraction. Although nonviable tissue should be removed, questionable areas of skin should be replaced gently.

Early, skillful repair of soft tissue injuries provides the best result. Local anesthetics that contain epinephrine are used to allow adequate wound cleansing and hemostasis. After the wound is irrigated and debrided, it is carefully closed. The possibility of injury to deeper structures (e.g., facial nerve, lacrimal apparatus, parotid duct) is considered next (Fig. 3-18). Although rapid assessment of facial nerve function is possible in the awake, cooperative patient, it can be extremely difficult in the multiply injured or comatose patient. Ideally, facial nerve injuries should be identified on initial physical examination so that repair may be planned. Parotid duct injuries should be suspected when a cheek laceration crosses a line from the tragus of the ear to the base of the nose.

Figure 3-18   Anatomy of the parotid gland showing Stensen’s duct and the relation of the facial nerve to the parotid gland and the face.

Injuries around the eyelids should be carefully evaluated because of the precision of repair required and the possibility of injury to the lacrimal apparatus. Debridement must be conservative in areas as the eyebrows, eyelids, nose, ears, and lips. Because these areas are extremely difficult to reconstruct, it is better to repair questionably ischemic areas, even if a minor revision is required later, than to sacrifice large portions of usable tissue. However, obviously nonviable tissue must be debrided.

Treatment of specific injuries (e.g., abrasions, lacerations) is similar to that in other parts of the body. Lacerations around the lip and other such areas require independent reconstruction of the muscle layers. For most injuries, topical antibiotic ointments are adequate to keep the wound clean and moist. Their antimicrobial component has minimal effect. Systemic antibiotics are not routinely required in facial injuries unless there is massive gross contamination or open injury to deeper structures (e.g., cartilage, bone). Tetanus prophylaxis should always be considered. Sutures are left in place for 5 to 6 days. In significantly contused and crushed tissue, sutures may be left a few days longer. Although the initial injury and the patient’s genetic makeup are the main determinants in the outcome of healing, appropriate initial handling of the wound is also an important factor.

Simple lacerations are appropriately repaired by a generalist who uses careful technique. More complex injuries that involve stellate lacerations, crush injuries, or devitalized or avulsed tissue should be referred to a specialist. Likewise, significant injuries to the eyelids and injuries that involve deeper structures (e.g., nerve injury, parotid duct injury, fractures) require prompt referral.

Facial Fractures

General Principles

Facial fractures are common in patients who have traumatic injuries. Common causes include motor vehicle accidents, assaults, falls, and athletic injuries. These fractures may be open or closed. The overlying tissue may be significantly injured or contused in closed injuries. A history of the injury often indicates the facial area involved. The nasal bone and the zygomatic–malar area are the most commonly injured areas, followed by the mandible and the maxilla. Many patients have multiple facial fractures.

Most facial fractures can be diagnosed based on physical examination, which should include gentle examination and palpation of the facial bones. A fracture is suspected if there is any mobility of facial bones, asymmetry, palpable bony step-offs, extraocular muscle irregularities, sensory loss, localized pain or tenderness, or malocclusion of the teeth. This examination should be followed by radio-graphic evaluation after the cervical spine is cleared. Of patients with significant facial injuries, 15% to 25% have concomitant cervical spine injuries. The possibility of skull fracture and intracranial injury is also evaluated.

X-ray evaluation consists of a complete facial bone series, which includes the Water’s, anterior–posterior, and lateral views. The Water’s view, an oblique anterior–posterior projection, shows most clearly the entire facial complex and is most helpful. Currently, however, computed tomographic (CT) scans in both the axial and coronal planes are the most accurate method of visualizing complex fractures. Three-dimensional CT scans or reconstructions are available in many centers. However, they add little to the acute management of facial fractures over what can be learned from routine CT scans. Mandibular x-ray evaluation is best obtained with the Panorex (panoramic x-ray) view. This specialized x-ray is superior to plain films of the mandible. However, in most facilities, the patient must be upright, a difficult position for the patient with multiple injuries.

After facial fractures are identified, the urgency of their treatment is assessed. Urgency depends on the likelihood of continued bleeding, cerebrospinal fluid (CSF) leak, or loss of airway because of shifting oropharyngeal structures. Early consultation with all services that treat facial fractures should be made. If the patient is stable and treatment is not urgent, repair of the facial fractures may be appropriately delayed for up to 5 to 7 days without adverse effects. This interval allows adequate time for evaluation and treatment of other injuries and for reduction of facial edema. CT scan examination can also assess and evaluate mandibular injury.

The principal goal of facial fracture reconstruction is the restoration of normal (premorbid) function and appearance. This goal is achieved by precise, anatomic reconstruction of all fractured bone segments, usually by open reduction and internal fixation. Although closed reduction may be adequate for simple fractures, internal fixation with interosseous wires or with plates or screws is usually performed. The bony pieces should be replaced if possible into the defect. If these bony fragments are unusable, immediate bone grafts should be considered, providing there is adequate soft tissue surrounding the structures.

Mandibular Fractures

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