Ebook Key notes on plastic surgery (2/E): Part 1

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Key Notes on Plastic Surgery Adrian Richards MBBS, MSc, FRCS (Plast) Plastic and Cosmetic Surgeon Aurora Clinics Princes Risborough UK Hywel Dafydd MB BChir, MA, MSc, FRCS (Plast) Specialty Registrar The Welsh Centre for Burns and Plastic Surgery Morriston Hospital Swansea UK SECOND EDITION F O R E W O R D B Y P R O F E S S O R F U-C H A N W E I This edition first published 2015 © 2015 by John Wiley & Sons, Ltd © 2002 by Blackwell Science Ltd Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom Library of Congress Cataloging-in-Publication Data Richards, Adrian M., author Key notes on plastic surgery / Adrian Richards, Hywel Dafydd ; foreword by professor Fu-Chan Wei – Second edition online resource Includes bibliographical references and index Description based on print version record and CIP data provided by publisher; resource not viewed ISBN 978-1-118-75686-7 (Adobe PDF) – ISBN 978-1-118-75699-7 (ePub) – ISBN 978-1-4443-3434-0 (pbk.) I Dafydd, Hywel, author II Title [DNLM: Surgery, Plastic WO 600] RD119 617.9′ 52 – dc23 2014033321 A catalogue record for this book is available from the British Library Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books Cover image: © iStock.com/youngvet Cover design by Andy Meaden Set in 9.5/12pt Meridien by Laserwords Private Limited, Chennai, India 2015 Contents Foreword iv Preface v Dedications vi Acknowledgements vi Abbreviations vii General Principles Skin and Soft Tissue Lesions The Head and Neck 133 The Breast and Chest Wall 264 The Upper Limb 309 The Lower Limb 422 The Trunk and Urogenital System 459 Burns 490 Aesthetic Surgery 530 Ethics, the Law and Statistics 591 Index 605 10 80 iii Foreword This second edition of Key Notes on Plastic Surgery distills the breadth and depth of the entire specialty into a compact format Clear, concise, accurate and accessible – that is what the trainee desires when refreshing their memory of conditions during clinic, of reconstructive algorithms before operating, and of the entire syllabus when preparing for plastic surgery board examinations Key Notes on Plastic Surgery fulfils this niche admirably A consistent balance has been struck between prose and bullet points throughout the book Key Notes on Plastic Surgery fosters understanding, facilitates the commitment of information to memory, and provides structure to ease the recall of facts and principles One can rapidly glean key information with a glance at the page and yet solidify an understanding with a few minutes’ read The textual formatting and presentation of information is where this book particularly shines Key Notes on Plastic Surgery will be embraced as a trusted companion by trainees all over the world as they progress through training and sit for their board examinations And when they become established plastic surgeons, Key Notes on Plastic Surgery will take pride of place on their bookshelves as a reliable quick reference handbook for teaching the next generation I highly recommend Key Notes on Plastic Surgery to all aspiring, training and established plastic surgeons worldwide Fu-Chan Wei, MD, FACS Distinguished Chair Professor Chang Gung University Medical College Taipei, Taiwan Academician Academia Sinica Taiwan iv Preface Hywel Dafydd has updated and improved the first edition of Key Notes on Plastic Surgery He has worked tirelessly to include new and better diagrams and improve the content whilst maintaining the book’s ethos – to succinctly communicate the essentials of Plastic Surgery We hope you enjoy the book and find it helpful in making you a better Plastic Surgeon Adrian Richards The first edition of Key Notes has proved to be exceptionally popular for over a decade Accessible, informative and succinct, it became the preferred handbook for innumerable plastic surgery trainees It was typeset with enough ‘white space’ to accommodate trainees’ notes and sketches as they approached their final plastic surgery examination Nevertheless, an update was much-needed: the field of plastic surgery has moved on apace and a detailed British plastic surgery syllabus was introduced The material of the first edition has been updated, rewritten and expanded with several new sections to reflect this In addition, a new chapter is provided: ‘Ethics and the law’ The number of diagrams has more than doubled, which should help with learning the ‘essentials’, such as cleft lip repair and eyelid anatomy Key Notes is now more complete and, although necessarily larger, remains true to the format and style of the first edition We hope that Key Notes continues to be useful to plastic surgeons worldwide Hywel Dafydd v Dedications AR – To my Family, Helena, Josie, Ciara, Alfie and Ned HD – For Jenny and Ioan Acknowledgements As any Plastic Surgeon will tell you, the training and practice of the speciality takes dedication and hard work Writing a book in your free time adds to this and requires patience and support from your family For this reason I would like to thank my family Helena, Josie, Ciara, Alfie and Ned for their constant support I would also like to thank my surgical mentors of whom there were many – in particular Brent Tanner and Michael Klaassen Adrian Richards I would like to thank my wife Jenny and my son Ioan for their love and patience Jenny also helped edit final drafts for brevity Thank you Per Hall for inspiring me to become a plastic surgeon Thanks to those who have trained me over the years in Cambridge, Wellington, Leicester, Birmingham, Coventry, Swansea, Taipei, and Auckland Special thanks to Sarah Hemington-Gorse, Ian Josty, Dai Nguyen, Nick Wilson Jones, Tom Potokar, Peter Drew, Leong Hiew, Hamish Laing, Dean Boyce, Max Murison and Ian Pallister, who spent hours proofreading early drafts I am also grateful to Rhidian Dafydd LLB, Karen Wong and Chris Wallace, who checked much of the text for accuracy Tom Macleod has been a constant source of support and encouragement, and did a great deal of preparatory work on many of the chapters The book could not have been written without the staff of Morriston Hospital’s library They sourced over 600 references from three centuries without as much as a grumble: thank you Anne, Sue, Rita and Lisa Hywel Dafydd vi Abbreviations 5-FU ABC ABPI AC ACPA ACR ADH ADM ADM AER AFX AICAP AIDS AIN AJCC AK ALCL ALH ALS ALT ANOVA AO AP APB APC APL APR APTT ARDS ASIS ASSH ATG ATLS AVA AVM AVN BAAPS BAHA 5-fluorouracil Acinetobacter baumanii-calcoaceticus ankle brachial pressure index alternating current anti-citrullinated protein antibody American College of Rheumatology atypical ductal hyperplasia abductor digiti minimi acellular dermal matrix apical ectodermal ridge atypical fibroxanthoma anterior intercostal artery perforator (flap) acquired immune deficiency syndrome anal intraepithelial neoplasia American Joint Committee on Cancer actinic keratosis anaplastic large T-cell lymphoma atypical lobular hyperplasia anti-lymphocyte serum anterolateral thigh (flap) analysis of variance Arbeitsgemeinschaft für Osteosynthesefragen anteroposterior abductor pollicis brevis antigen presenting cell abductor pollicis longus abdomino-perineal resection activated partial thromboplastin time adult respiratory distress syndrome anterior superior iliac spine American Society for Surgery of the Hand anti-thymoglobulin Advanced Trauma Life Support arteriovenous anastomosis arteriovenous malformation avascular necrosis British Association of Aesthetic Plastic Surgeons bone-anchored hearing aid vii viii Abbreviations BAPRAS BAPS BCC BDD BEAM BMI BMP BOA BPD BRAF BRBN BSA BSSH BXO cAMP CCNE CEA CFNG CI CIN CL CM CMCJ CMN CNS CO COX CP CPAP CPR CRP CRPS CSAG CSF CT CTA CTLA CTS CVP CVS DASH DBD DC DCIA British Association of Plastic, Reconstructive and Aesthetic Surgeons British Association of Plastic Surgeons basal cell carcinoma body dysmorphic disorder bulbar elongation and anastomotic meatoplasty body mass index bone morphogenetic protein British Orthopaedic Association biliopancreatic diversion B-Raf serine/threonine-protein kinase blue rubber bleb naevus (syndrome) body surface area British Society for Surgery of the Hand balanitis xerotica obliterans cyclic adenosine monophosphate Comité Consultatif National d’Ethique cultured epithelial autograft cross facial nerve grafting cranial index cervical intraepithelial neoplasia cleft lip capillary malformation carpometacarpal joint congenital melanocytic naevus central nervous system carbon monoxide cyclooxygenase cleft palate continuous positive airways pressure cardiopulmonary resuscitation C-reactive protein complex regional pain syndrome Clinical Standards Advisory Group cerebrospinal fluid computed tomography composite tissue allotransplantation cytotoxic T-lymphocyte antigen carpal tunnel syndrome central venous pressure cardiovascular system Disabilities of the Arm, Shoulder and Hand dermolytic bullous dermatitis direct current deep circumflex iliac artery Abbreviations DCIS DD DEXA DFAP DFSP DICAP DIEA DIEP DIPJ DIY DMARD DNA DOPA DOT DRUJ DTH EAST EBV ECG ECRB ECRL ECU EDC EDM EGF EIP ELND EEMG ELD EMG EMLA ENT EO EPB EPL EPUAP ER ERK ESBL ESR EULAR FAMM FAMM FBC ductal carcinoma in situ Dupuytren’s disease dual-energy X-ray absorptiometry deep femoral artery perforator (flap) dermatofibrosarcoma protuberans dorsal intercostal artery perforator (flap) deep inferior epigastric artery deep inferior epigastric perforator (flap) distal interphalangeal joint it yourself disease-modifying antirheumatic drug deoxyribonucleic acid dihydroxyphenylalanine double-opposing tab distal radio-ulnar joint delayed type hypersensitivity elevated arm stress test Epstein-Barr virus electrocardiogram extensor carpi radialis brevis extensor carpi radialis longus extensor carpi ulnaris extensor digitorum communis extensor digiti minimi epidermal growth factor extensor indicis proprius elective lymph node dissection evoked electromyography extended latissimus dorsi (flap) electromyography eutetic mixture of local anaesthetic ear, nose and throat external oblique extensor pollicis brevis extensor pollicis longus European Pressure Ulcer Advisory Panel oestrogen receptor extracellular-signal-regulated kinase extended-spectrum beta-lactamase erythrocyte sedimentation rate European League Against Rheumatism facial artery musculomucosal (flap) familial atypical mole and melanoma (syndrome) full blood count ix 298 Chapter Full thickness skin grafts • Can be harvested from the contralateral areola during simultaneous contralateral breast symmetrisation • Alternatively, obtained from non-hairy skin lateral to the labia majora ∘ Pigmentation of this site approximately matches areola Chest wall reconstruction • Indicated following: ∘ Tumour resection ∘ Infection ∘ Radiation injury ∘ Trauma Embryology and anatomy • Ribs, costal cartilages and sternum begin to develop during the 6th week • Sternum arises from paired longitudinal mesodermal bars ∘ Fuse cranial to caudal during the 10th week, forming a cartilaginous sternal plate ∘ Failure of fusion leads to congenital cleft sternum • 1st–7th ribs extend ventrally to fuse with the sternum in the 9th week ∘ Known as true ribs ∘ 8th–10th are false ribs; 11th and 12th are floating ribs • Intercostal spaces contain three muscles and associated neurovascular bundle (NVB): ∘ External intercostal muscle ∘ Internal intercostal muscle ∘ Innermost intercostal muscle ∘ NVBs run between internal and innermost muscle layers, along the rib’s inferior border • Dominant sternal blood supply is from paired internal mammary arteries • Inspiratory muscles pull the ribcage upwards: ∘ Sternocleidomastoid ∘ Scalenes • Expiratory muscles pull the ribcage downwards: ∘ Rectus abdominis ∘ External oblique ∘ Internal oblique • Extensive trauma and tumour resection disrupts chest wall integrity, leading to paradoxical chest movement known as flail chest • When a flail segment, usually >5 cm, loses continuity with the surrounding chest wall, ventilation becomes inefficient ∘ Defects 3.25 • Can be corrected by: ∘ Ribcage reconstruction ∘ Insertion of a prosthetic moulage Reconstruction of the ribcage Ravitch procedure (1949) Perichondrial flaps elevated from costal cartilages Resection of abnormal costal cartilages; preservation of costochondral junction Osteotomies of upper and lower sternum, which is mobilised anteriorly Stabilisation of the sternum in its new position with wires or bars Pectoralis muscles sutured over the sternum in the midline • Ravitch’s original description did not use perichondrial flaps or preserve the costochondral junction, resulting in damage to NVBs and rib growth centres Sternal turnover operation The sternum is mobilised, based on an internal mammary pedicle Turned over and shaped with anterior osteotomies Replaced and stabilised with stainless steel wires Nuss repair (1988) Small incisions are made in the lateral chest wall A shaped convex metal bar is inserted subcutaneously as far as the sternum The bar is passed retrosternally under video thoracoscopic guidance, then re-enters the subcutaneous plane on the other side to reach the opposite lateral chest wall The bar is inserted with its convexity facing posteriorly, then flipped over when correctly positioned ∘ Results in sternal elevation with subsequent remodelling of ribs and costal cartilages ∘ Not effective in adults because the chest is less flexible 300 Chapter Insertion of a prosthetic moulage • Cosmetic treatment using a custom-made prosthesis • The deformity is imaged and a moulage fabricated from porous polyethylene (Medpor®) or solid silicone, based on 3D reconstructions • The implant is placed in a subcutaneous pocket Pectus carinatum • Second most common congenital chest wall abnormality • Occurs once every 2500 live births; male:female ratio 4:1 • Most patients are asymptomatic; they may complain of pain when lying prone • Can be corrected by: ∘ Non-operative management with a brace – Worn 14 hours a day for years; provides continuous anteroposterior compression – Progressively remodels the chest ∘ Operative management by modifications of the Ravitch or Nuss procedure Poland’s syndrome • Described by Alfred Poland (1841) while an anatomy demonstrator at Guy’s Hospital, London • Originally described absence of sternocostal part of pectoralis major (intact clavicular origin), absence of pectoralis minor, hypoplastic serratus anterior and external oblique Clinical features • Characterised by unilateral chest wall and upper limb abnormalities • Variable manifestation from mild to severe • Affects one in 30,000 • Male:female ratio 2–3:1, but more females seek treatment (for breast asymmetry) • Most cases are sporadic; some cases run in families, suggesting a genetic basis • Twice as common on the right side in males; rarely bilateral • Deformities rarely cause functional problems • Thought to be caused by a vascular developmental anomaly of the subclavian artery in the 6th week • Associated with Möbius and Klippel–Feil syndromes ∘ These may be caused by more proximal involvement of the subclavian artery Chest wall • Absence of the sternocostal head of pectoralis major is pathognomonic • Absence or hypoplasia of breast and NAC – may be displaced superiorly • Lack of subcutaneous fat and axillary hair • Abnormalities of pectoralis minor, infraspinatus, supraspinatus, LD, serratus anterior, external oblique and rectus abdominis • Abnormalities of the rib cage with possible lung herniation Upper limb • Short arms • Brachysyndactyly The Breast and Chest Wall 301 Surgical treatment • Surgery is targeted at cosmetic deformities: Breast • Asymmetry in adolescents can be treated with tissue expanders or expander/implant ∘ Allows adjustments to match the contralateral breast as it develops • Once breast development is complete, the expander can be replaced with: Definitive implant covered with LD flap or ADM Wholly autologous tissue: – Pedicled ipsilateral LD or free contralateral LD – Omental flap – TRAM/DIEP flap – Lipomodelling has been described Chest • LD can recreate the anterior axillary fold and mask the infraclavicular hollow ∘ The origin is transposed anteriorly; the humeral insertion is detached and sutured more anteriorly on the bicipital groove • When multiple ribs are hypoplastic or absent, contralateral costal grafts can be used ∘ Donor rib periosteum is left behind to encourage regeneration • Chest implants can be used in males, but may appear unnatural due to lack of muscle cover Sternal wound infection Superficial infection involves skin, subcutaneous tissue and pectoralis fascia ∘ Usually eradicated with systemic antibiotics Deep infection, or mediastinitis, is life-threatening; affects 1–5% of median sternotomies ∘ Requires aggressive surgical debridement and flap coverage • Risk factors: ∘ Diabetes ∘ Obesity ∘ Chronic obstructive pulmonary disease ∘ Osteoporosis ∘ Smoking ∘ Use of bilateral internal mammary arteries ∘ Revision operations ∘ Prolonged stay on the intensive care unit • Success using rigid fixation with plates and screws have led some surgeons to use this method in preference to cerclage wires for sternal repair in high risk patients Classification of sternal infection • Pairolero classified infected median sternotomy wounds: • Type I ∘ Typically appears within the first week after sternotomy ∘ Characterised by serosanguinous discharge without evidence of cellulitis, costochondritis or osteomyelitis – Requires systemic antibiotics and sometimes a single-stage operation 302 Chapter • Type II ∘ Typically appears between second and fourth weeks after sternotomy ∘ Characterised by purulent mediastinitis with osteomyelitis ± costochondritis – Requires debridement and removal of foreign material – Dead space management with a soft tissue flap • Type III ∘ Typically appears months to years after sternotomy ∘ Characterised by chronic draining sinus tracts with costochondritis, osteomyelitis and retained foreign bodies – Repeated debridements are usually required, followed by dead space obliteration with flaps Treatment Negative pressure wound therapy (NPWT) • Widespread use of NPWT on sternal wounds has led to: ∘ Reduced need for surgical intervention ∘ Reduced reoperation rates for persistent infections ∘ Curtailment of hospitalisation for patients • NPWT has the following effects on sternotomy wound infections: ∘ Increased local blood flow ∘ Decreased bacterial count ∘ Enhanced granulation tissue formation ∘ Chest stabilisation and improved respiratory function • Many can be treated with NPWT alone ∘ Useful for debilitated patients unable to withstand additional surgery • Factors predicting need for surgical intervention: ∘ Bacteraemia ∘ Wound depth >4 cm ∘ Bone exposure ∘ Sternal instability • In such cases, NPWT is used as bridging therapy to definitive surgical treatment Surgery • Pairolero types II and III require surgical debridement of all necrotic and infected soft tissue and bone, with removal of sternal wires or other foreign bodies • Tissue is submitted for microbiological analysis • Dead space is filled with well-vascularised tissue: Pectoralis major flap • Can be used in one of two ways: Turnover – based on medial perforators from the internal mammary artery (if intact) Rotation advancement – based on pectoral branches of the thoracoacromial axis – Can include part of anterior rectus sheath to cover inferior sternum The Breast and Chest Wall 303 Rectus abdominis flap • Can be used in one of two ways: Muscle only Myocutaneous – The skin paddle is oriented vertically, known as a vertical rectus abdominis myocutaneous (VRAM) flap • Supplied by superior epigastric artery ∘ This is the continuation of the internal mammary artery ∘ Flap perfusion may be compromised if internal mammary vessels are used for coronary artery bypass – In such cases, muscle perfusion may be maintained from the 8th intercostal artery • Risk of abdominal hernia can be reduced by transposing the muscle while leaving rectus sheath in situ on the abdomen Omental flap • Based on either of the gastro-epiploic pedicles • The flap is skin grafted after transposition • Contours easily into the recesses of a sternal wound • Has intrinsic immunological function • Complications related to laparotomy are minimised by laparoscopic harvest • There is a risk of spreading infection between chest and abdominal cavities Reconstruction following tumour ablation and trauma • Most agree that chest wall defects >5 cm, or segmental loss of four contiguous ribs, benefit from reconstruction • Anterior and posterior defects are better tolerated than lateral defects • Radiotherapy defects may be better tolerated due to the stabilising properties of fibrosis • Reconstruction should consider skeletal support and soft tissue cover Skeletal support • Provided by autologous tissue or alloplastic materials Autologous tissue • Split rib grafts • Iliac crest • Fibula ∘ Vascularised bone preferred – less resorption, greater rates of union Alloplastic materials Mesh and composite implants • Polypropylene knitted mesh ∘ Permanent ∘ Induces fibrovascular infiltration with incorporation into surrounding tissues 304 Chapter ∘ • • • • • • • Available as single- and double-knit fabrics: – Single-knit (expandable in one direction, rigid in another): Marlex® – Double-knit (expandable in both directions): Prolene® Polyester: Mersilene®, Dacron® Polyglycolic acid: Dexon® Expanded polytetrafluoroethylene (e-PTFE): Gore-Tex® Polydioxanone: PDS® Polyglactin: Vicryl® Composite techniques allow a construct to be contoured while maintaining rigidity ∘ Most common is polypropylene mesh and polymethylmethacrylate (PMMA): – Mesh is cut generously, leaving excess to secure the construct to the defect – PMMA is then added to fill the defect – A second layer of mesh is placed on the PMMA, creating a sandwich – Vital structures should be protected because PMMA produces heat as it cures Mesh repair of previously irradiated or contaminated defects increases risk of infection and implant exposure Biological materials • Most commonly used are ADMs derived from human or porcine sources • Most ADMs are gradually revascularised and remodelled into autologous tissue, while maintaining their structural integrity • More resistant to infection and more readily incorporated into irradiated wounds than synthetics • Classification of biologicals: ∘ Allografts (human ADM) – From cadaveric dermal allografts – AlloDerm® is processed human dermis – Cellular components are chemically and physically removed, while preserving extracellular matrix and basement membrane – Widely used in the United States, but not currently available in the United Kingdom for this purpose ∘ Xenografts Porcine Permacolđ crosslinked ADM Stratticeđ non-crosslinked ADM Surgisisđ small bowel submucosa Bovine • Tutopatch® – pericardium • Veritas® – pericardium • Surgimend® – non-crosslinked ADM Soft tissue cover • Defects not requiring stabilisation can be reconstructed with soft tissue only • Most reconstructions are accomplished with pedicled flaps: The Breast and Chest Wall 305 Muscle flaps (with or without a skin paddle) • Pectoralis major ∘ For central, supraclavicular, lateral and axillary defects ∘ Can also be transposed to obliterate intrathoracic dead space • LD ∘ Useful for large anterior, anterolateral, posterior midline and paramedian defects • Rectus abdominis ∘ For anterior defects, particularly inferior to the xiphisternum ∘ The skin paddle can be transversely or vertically oriented • External oblique ∘ Rarely used; useful for anterolateral chest wall ∘ Type V blood supply: dominant vessel is deep circumflex iliac artery, with secondary segmental supply from 5th–12th posterior intercostal arteries ∘ The overlying skin paddle is usually designed as a laterally-based hatchet flap ∘ Can reach the 2nd intercostal space and up to cm beyond the midline Other pedicled flaps • Local tissues can be mobilised as fasciocutaneous or perforator flaps • Omentum can be used for dead space obliteration and soft tissue cover Free tissue transfer • Indications for free flaps include: ∘ Salvage after the failure of pedicled flaps ∘ Large defects unreconstructible with pedicled flaps, particularly after radiotherapy ∘ Defects inaccessible to pedicled flaps ∘ Intrathoracic deadspace • Most common free flaps used for chest wall defects: ∘ Tensor fasciae latae – Provides soft tissue cover and thick, strong fascia ∘ Latissimus dorsi – Including serratus anterior on the same pedicle allows coverage of large defects ∘ TRAM, VRAM or DIEP – Free transfer is more versatile for insetting than the pedicled equivalent ∘ Anterolateral thigh flap – Can include fascia lata for support and vastus lateralis for bulk ∘ Scapular and parascapular flaps – Supplied by the circumflex scapular artery, a branch of the subscapular artery – Gives a transverse cutaneous scapular branch and vertical parascapular branch Posterior trunk reconstruction • Most defects result from: ∘ Congenital causes – Spina bifida 306 Chapter ∘ Acquired causes – Trauma – Iatrogenic, following spinal instrumentation – Tumour – Pressure ulcer • Reconstruction is usually best accomplished with a flap: ∘ Healing by secondary intention or skin grafts is not durable ∘ Exposed bone or implants require vascularised coverage Flap options Cervical • Trapezius flap ∘ Raised as muscle or myocutaneous flap ∘ Based on the superficial branch of transverse cervical artery, from thyrocervical trunk ∘ Superior fibres of the muscle are left intact to avoid ‘drop shoulder’ Upper thoracic • LD flap • Trapezius flap ∘ Can be raised on posterior intercostal perforators, but rarely required if LD is available • Scapular or parascapular flap Lower thoracic • LD flap ∘ Can be raised on secondary segmental supply from posterior intercostal arteries • Intercostal artery perforator flaps ∘ Can be used if muscle is not required for dead space obliteration • Omentum ∘ Used as a last resort Lumbar • Lumbar artery perforator flap ∘ Has largely superseded the transverse lumbosacral flap, which is random pattern ∘ Basing the flap on an identified perforator may be more reliable • SGAP flap • LD flap ∘ Based on its segmental supply; may not reach inferior lumbar defects • Omentum Further reading Breast reduction and mastopexy Benelli L A new periareolar mammaplasty: the "round block" technique Aesthetic Plast Surg 1990;14(2): 93–100 The Breast and Chest Wall 307 Hall-Findlay EJ Vertical breast reduction with a medially-based pedicle Aesthet Surg J 2002;22(2): 185–94 Hamdi M, Van Landuyt K, Tonnard P et al Septum-based mammaplasty: a surgical technique based on Würinger’s septum for breast reduction Plast Reconstr Surg 2009;123(2):443–54 Regnault P Breast ptosis Definition and treatment Clin Plast Surg 1976;3(2):193–203 Robbins TH A reduction mammaplasty with the areola–nipple based on an inferior dermal pedicle Plast Reconstr Surg 1977;59(1):64–7 Rohrich RJ, Thornton JF, Jakubietz RG et al The limited scar mastopexy: current concepts and approaches to correct breast ptosis Plast Reconstr Surg 2004;114(6):1622–30 Breast augmentation Basu CB, Jeffers L The role of acellular dermal matrices in capsular contracture: a review of the evidence Plast Reconstr Surg 2012;130(5 Suppl 2):118S–24 Cunningham B The Mentor Core Study on silicone MemoryGel breast implants Plast Reconstr Surg 2007;120 (7 Suppl 1):19S–29 de Jong D, Vasmel WL, de Boer JP et al Anaplastic large-cell lymphoma in women with breast implants JAMA 2008;300(17):2030–5 Khouri RK, Eisenmann-Klein M, Cardoso E et al Brava and autologous fat transfer is a safe and effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study Plast Reconstr Surg 2012;129(5):1173–87 Little G, Baker JL Jr., Results of closed compression capsulotomy for treatment of contracted breast implant capsules Plast Reconstr Surg 1980;65(1):30–3 Medicines and Healthcare products Regulatory Agency Information for women considering breast implants 2012 http://www.mhra.gov.uk (last accessed 18th July 2014) Spear S Augmentation/mastopexy: “surgeon, beware” Plast Reconstr Surg 2003;112(3):905–6 Spear SL, Carter ME, Ganz JC The correction of capsular contracture by conversion to “dual-plane” positioning: technique and outcomes Plast Reconstr Surg 2003;112(2):456–66 Spear SL, Murphy DK Allergan Silicone Breast Implant U.S Core Clinical Study Group Natrelle round silicone breast implants: core study results at 10 years Plast Reconstr Surg 2014;133(6):1354–61 Tebbetts JB Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types Plast Reconstr Surg 2001;107(5):1255–72 Tebbetts JB, Adams WP Five critical decisions in breast augmentation using five measurements in minutes: the high five decision support process Plast Reconstr Surg 2006;118(7 Suppl):35S–45 Tuberous breast von Heimburg D Refined version of the tuberous breast classification Plast Reconstr Surg 2000;105(6): 2269–70 von Heimburg D, Exner K, Kruft S et al The tuberous breast deformity: classification and treatment Br J Plast Surg 1996;49(6):339–45 Pacifico MD, Kang NV The tuberous breast revisited J Plast Reconstr Aesthet Surg 2007;60(5):455–64 Gynaecomastia Simon BE, Hoffman S, Kahn S Classification and surgical correction of gynecomastia Plast Reconstr Surg 1973;51(1):48–52 Webster JP Mastectomy for gynecomastia through a semicircular intra-areolar incision Ann Surg 1946; 124(3):557–75 308 Chapter Breast cancer and reconstruction Association of Breast Surgery at Baso 2009 Surgical guidelines for the management of breast cancer Eur J Surg Oncol 2009;35(Suppl 1):1–22 Chan CW, McCulley SJ, Macmillan RD Autologous fat transfer – a review of the literature with a focus on breast cancer surgery J Plast Reconstr Aesthet Surg 2008;61(12):1438–48 Dewis R, Gribbin J Breast Cancer: Diagnosis and Treatment An Assessment of Need NICE Clinical Guidelines, No 80–81S Cardiff, UK: National Collaborating Centre for Cancer, 2009 Forrest AP, Everington D, McDonald CC et al The Edinburgh randomized trial of axillary sampling or clearance after mastectomy Br J Surg 1995;82(11):1504–8 Galimberti V, Zurrida S, Zanini V et al Central small size breast cancer: how to overcome the problem of nipple and areola involvement Eur J Cancer 1993;29A(8):1093–6 Jeevan R, Cromwell D, Browne J et al National Mastectomy and Breast Reconstruction Audit 2011 Leeds: The NHS Information Centre, 2011 http://www.hscic.gov.uk (last accessed 18th July 2014) Nahabedian MY Acellular dermal matrices in primary breast reconstruction: principles, concepts, and indications Plast Reconstr Surg 2012;130(5 Suppl 2):44S–53 Chest wall reconstruction Arnold PG, Pairolero PC Chest-wall reconstruction: an account of 500 consecutive patients Plast Reconstr Surg 1996;98(5):804–10 Blanco FC, Elliott ST, Sandler AD Management of congenital chest wall deformities Semin Plast Surg 2011;25(1):107–16 Fokin AA, Robicsek F Poland’s syndrome revisited Ann Thorac Surg 2002;74(6):2218–25 Hester TR Jr., Bostwick J 3rd., Poland’s syndrome: correction with latissimus muscle transposition Plast Reconstr Surg 1982;69(2):226–33 Mahabir RC, Butler CE Stabilization of the chest wall: autologous and alloplastic reconstructions Semin Plast Surg 2011;25(1):34–42 Singh K, Anderson E, Harper JG Overview and management of sternal wound infection Semin Plast Surg 2011;25(1):25–33 ... protection Protection against UV light Protection against microbiological invasion Prevention of fluid loss Key Notes on Plastic Surgery, Second Edition Adrian Richards and Hywel Dafydd © 2 015 John... established plastic surgeons, Key Notes on Plastic Surgery will take pride of place on their bookshelves as a reliable quick reference handbook for teaching the next generation I highly recommend Key Notes. .. for plastic surgery board examinations Key Notes on Plastic Surgery fulfils this niche admirably A consistent balance has been struck between prose and bullet points throughout the book Key Notes