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Areas over bone where padding is needed (e.g., the ischial tuberosity in a patient with pressure sores)

Vascular patency may be assessed by color, temperature, Doppler flowmetry, fluoroscanning, and laser Doppler.

D Reconstructive breast surgery

Techniques are available for treatment of micromastia (small breasts), macromastia (oversized breasts), and gynecomastia and for reconstruction following mastectomy. Because the breast is frequently viewed as a symbol of femininity, there is much emotional overlay in this type of surgery. Careful planning and realistic goals are necessary for patient satisfaction.

Micromastia is present when a patient feels that she lacks development of one or both breasts.

Treatment is by augmentation with a prosthetic implant that can be placed either subglandularly (between the breast and the pectoralis major muscle) or submuscularly (underneath the pectoralis major muscle). The fill material for the prosthetic implant is either intraoperatively injected normal saline or factory -filled silicone. Silicone implants have the advantage of a more natural feel and shape. However, concerns about the potential health risks associated with silicone implants prompted the Food and Drug Administration (FDA) to ban their use in 1992 except in women who have undergone mastectomies or who are part of research studies. On October 16, 2003, an FDA advisory panel recommended that the government approve the use of silicone implants under certain conditions. On January 7, 2004, the FDA rejected the panel's recommendations pending further investigation. Studies by the Mayo Clinic, Harvard Medical School, and the National Academy of Sciences' Institute of Medicine panel found no evidence that leaked silicone from implants causes systemic disease.

Complications, although rare, include infections and hematoma formation. A capsular contracture may form around the implant, which can lead to asymmetry and discomfort. This condition may require a subsequent surgical scar release and is more common when the implant is in the subglandular position.

Explantations, or removal of implants , are becoming increasingly common. Rupture of the silicone gel implant is difficult to diagnose on mammograms, and either ultrasound or magnetic resonance imaging (MRI) is a better option. Frequently, there is no change in the breast of a woman with a ruptured silicone gel implant. If a saline implant ruptures, it generally deflates in a matter of days, making the diagnosis quite easy.

Macromastia is present when the patient feels that she has abnormally large breasts. Frequently, macromastia can be debilitating because of neck and back pain.

Treatment. Various techniques have been described. All involve resecting breast tissue and the inferior breast skin, transposition of the nipple–areolar complex superiorly, and closure of the resultant flap defects. All resected specimens should be examined histologically because occult carcinoma may be present, although rarely is.

Complications include hematoma formation, infection, change in nipple sensation, and necrosis.

Mammary ptosis , or drooping of the breast, is present when the nipple has extended below the inframammary fold. The breast skin envelope is larger than the underlying breast parenchyma. This condition usually occurs after significant weight loss, and it can occur after childbirth.

Treatment involves skin excision similar to breast reduction incisions; however, very little or no breast tissue is removed.

commonly used in breast reconstruction after a mastectomy.

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Free flaps are occasionally indicated. The most common types are the free TRAM and free gluteus maximus myocutaneous flaps for breast reconstruction.

Nipple–areola reconstruction is usually done as a second stage. The nipple is reconstructed most commonly with local flaps and a skin graft to reconstruct the areola. If necessary, the nipple–areola complex can be tattooed to increase pigmentation.

Occasionally, a mastopexy or reduction mammoplasty is necessary for the opposite breast to achieve symmetry.

Postoperative pain relief

Regional anesthesia includes peripheral nerve blocks, local wound infiltration, and epidural and spinal analgesia. Advantages of these types of anesthesia are reduced rates of blood loss, deep venous thrombosis (DVT), and adverse effects of general anesthesia as well as improved pain control. The pain pump, commonly used after breast reconstruction, breast augmentation, and abdominoplasty (procedures where there is a potential space) is a nonelectrical device that continuously delivers pain medication via very small catheters placed in the surgical site at the end of surgery. Commonly used medications are bupivacaine and lidocaine. The device delivers local anesthetic for approximately 48–72 hours, at which time the catheters can be removed by the patient at home.

Patient -controlled analgesia (PCA) allows the patient to self-administer narcotics via an infusion pump of which the dose, dose interval, and infusion rate are preset by the physician. The pump helps to provide the patient with optimal pain relief. The patient has around -the-clock access to narcotics that can be delivered the moment she experiences pain or prior to expected activity. This tends to decrease the apprehension that patients often feel postoperatively about delays in medication administration. Prior to discharge from the hospital, the patient is weaned from the PCA and is given oral pain medication.

E Reconstruction of congenital anomalies

(see Chapter 29)

Congenital anomalies may result from genetic or environmental factors. In most cases, an initiating environmental factor acts on a genetically predisposed individual. The inheritance risk for most anomalies remains low. The repair and reconstruction of many congenital anomalies do not fall within the scope of plastic surgery; examples include the gastrointestinal anomalies discussed in Chapter 29 .

Maxillofacial deformities can be reconstructed by craniofacial surgery.

Soft tissue and bony abnormalities can be reconstructed by a specialized team approach. Examples include:

Hypertelorism

Orbital dystopia

Treacher Collins syndrome

Facial clefts

Crouzon's disease

Apert's syndrome

Cleft lip may be unilateral, bilateral, or incomplete. It is seen in 1 in 1000 births and is more common in Asian children and male children. It is less common in blacks. Reconstruction is generally performed at approximately 3 months of age as determined by the “rule of tens”: 10 lb, 10 weeks of age, and 10 g of hemoglobin. Some surgeons prefer to operate in the neonatal period.

Cleft palate may occur as a defect in the primary or secondary palate or both. It occurs in 0.5 in 1000 births.

Reconstruction is performed before 2 years of age to aid in normal speech development. It commonly involves local flap advancement.

Secondary bone grafting is indicated before permanent teeth erupt if maxillary discontinuity exists.

Early attention to nutrition is important, because sucking is impaired.

F

Facial trauma frequently accompanies other major trauma. After ensuring adequate ventilation and circulation, attention should be directed initially to areas where trauma is more life threatening

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(i.e., the chest and abdomen) (see Chapter 21 I). Once the patient is stabilized, the facial structures can be examined systematically.

Soft tissue

Lacerations of the face bleed readily because of its rich blood supply. Bleeding is controlled by direct pressure and never by “blind” clamping. Control in the operating room may be necessary.

Lacerations may involve deeper structures, such as the facial nerve and parotid duct.

Most lacerations can be repaired by primary closure, following thorough debridement of all devitalized tissue.

Blunt trauma may result in contusions or associated fractures.

Many injuries of this type can be diagnosed initially by inspection; facial asymmetry, if present, should be noted.

Dental malocclusion may signify a mandibular or maxillary fracture.

Instability of the upper jaw may signify a maxillary fracture or midface fracture.

Pain on palpation at the nose, depression, or asymmetry may signify a nasal fracture.

Diplopia, malar deformity, enophthalmos, or hypoesthesia of the cheek may signify an orbital blow-out fracture.

Complete radiologic examination is essential. Operative stabilization is usually required.

FIGURE 26-7 A–C: Vaginal reconstruction with bilateral gracilis myocutaneous flap. D–E: Vaginal reconstruction with bilateral gracilis myocutaneous flap.

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Laser treatments to facial areas (most commonly, CO2 and erbium lasers) are used to treat photoaging of the skin. Other lasers are useful for treating spider veins, benign skin discoloration, and hair removal.

the more common lesions are discussed in this chapter. P.493

Common warts (verrucae vulgaris) occur most frequently in the second decade of life and may be transmitted by direct or indirect contact.

Etiology. They are caused by a member of the papovavirus family, which invades the stratum spinosum epidermidis, causing papillomatosis.

Clinical presentation. The fingers are the most common location. The lesions have a characteristic rough and elevated surface and can become tender.

Treatment involves minimal destruction of normal tissue. In many cases, the warts resolve spontaneously. Problematic lesions can be treated by:

Curettage and electrodesiccation

Freezing with liquid nitrogen

Chemotherapy with caustic agents

Cysts are fluid -filled cavities in the subcutaneous tissues; they may resemble solid tumors.

Epidermal inclusion cysts develop when epidermal cells are trapped in the subcutaneous tissue. Desquamation leads to the creation of a cavity. Excision is curative.

Sebaceous cysts result from blockage of a sweat gland, which causes the accumulation of sebum and the creation of a cyst. Excision is curative and prevents a recurrence. If infection is present, the cyst should be incised and drained before excision.

Dermoid cysts are congenital lesions that may occur later in life. If they occur in the midline (glabellar, nasal), a computed tomography (CT) scan is indicated because there may be intracranial communication. Treatment is by excision.

Ganglia can occur in areas of weakened retinaculum, with outpouching of underlying synovial structures. They occur most commonly on the hands and feet in areas subjected to trauma or inflammation. Excision is curative, but there can be recurrences, which are probably caused by inadequate resection of the ganglion's stalk and base.

Vascular birthmarks are frequently disturbing to the patient and family because they are cosmetically deforming. They are classified on the basis of their clinical and cellular characteristics.

Hemangiomas (strawberry marks) are characterized by increased number of mast cells during the proliferative phase and rapid postnatal growth. These elevated, red, soft, compressible lesions grow rapidly during the first year of life and are most commonly located on the head and neck area and extremities. Spontaneous regression is characteristic. Surgery or steroid therapy is indicated for lesions causing functional impairment (e.g., to the eyes, ears, throat). Rarely, platelet consumption occurs. Hemorrhage is uncommon, and there is usually minimal residual scarring.

Vascular malformations grow at the same rate as the patient; thus, they may not be obvious at birth. They have a normal number of mast cells and may be divided according to the predominant vascular tissue: capillary, venous, lymphatic.

Capillary malformations (capillary hemangioma, port -wine stains) are found on the face, chest, and extremities. They may be associated with Sturge -Weber and Klippel -Trenaunay - Weber syndromes. There is dilatation of the capillaries in the subpapillary, dermal, or subdermal layer. If the tumor is small, excision is curative. Treatment of larger lesions requires careful planning for optimal results. The laser has recently proved to be helpful in treatment.

Venous malformations (cavernous hemangiomas) involve a matrix of mature vessels in the subcutaneous tissues; frequently, they involve deeper structures, including muscle. These lesions may sequester platelets. After careful preoperative planning, treatment involves wide excision with attention to the involved structures. Occasionally, a direct sclerosant injection may be helpful.

Lymphatic malformations (lymphangioma, cystic hygroma) commonly cause hypertrophy of involved soft tissues. Surgical treatment is excision, and seroma is a common complication.

Arteriovenous malformations frequently remain stable in size and then expand. Treatment is by surgical excision.

Vascular tumors are frequently benign; they may cause concern because of their prominence.

Pyogenic granulomas are papular lesions that are commonly located on the face, chest, and fingers; the lesions develop rapidly and then stop enlarging after variable periods of growth. They tend to bleed freely. Surgical excision is usually curative.

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Spider nevi (telangiectasias) occur in all age groups and are commonly located on the face, chest, and extremities. They may arise during pregnancy and with cirrhosis. The lesion consists of a central arteriole with vessels resembling venules that radiate from the center. They rarely bleed, and treatment (i.e., laser therapy, electrodesiccation, or cryotherapy) is undertaken primarily for cosmetic reasons.

Glomus tumors, which are extremely painful, are located most frequently in the nail beds. Treatment is by excision.

Lipomas (fat tumors) can be found in any area of the body where fat is normally found, but they are most common on the neck, shoulders, back, and thighs. Malignant transformation is uncommon, and excision is curative.

Nerve tumors (see Chapter 18, IV F 1, 3) come in two varieties.

Neurilemomas arise from the Schwann cell sheath. They do not cause much pain, and they are treated by excision.

Neurofibromas involve masses of nerve and fibrous tissue and are related to von Recklinghausen's disease. They may undergo malignant degeneration.

Seborrheic keratosis is a light - to dark -brown raised papular lesion, which must be differentiated from malignant skin lesions. Treatment is by biopsy followed by curettage and electrodesiccation.

Keloids are abnormal accumulations of fibrous tissue, which extend above and beyond an area that was previously traumatized (as opposed to hypertrophic scars that remain within those confines). They occur more commonly in blacks. Treatment is by excision and pressure. Occasionally, adjuvant corticosteroid therapy is necessary.