PLASTIC SURGERY BOARD NOTES CRANIOMAXILLOFACIAL Embryology Five facial prominences: bilateral mandibular prominences, bilateral maxillary prominences,

frontonasal prominence 1. Maxillary prominences give rise to maxilla, zygoma, squamous part of temporal bone 2. Mandibular prominences give rise to body and ramus of mandible 3. Frontonasal: lateral and medial nasal, median palatine process, nasal placodes Nasal embryology Lateral nasal processes alae Medial nasal processes columella, nasal tip, philtrum, premaxilla Frontonasal processes bridge and root Branchial arches: Arch Nerve First: Meckels trigeminal nerve cartilage Muscles muscles of mastication, anterior belly digastric, mylohyoid, tensor tympani, tensor veli palatini muscles of facial expression, posterior belly digastric, stapedius, stylohoid stylopharyngeus pharyngeal constrictors
Skeletal structures

malleus, incus, mandible

Ligaments sphenomandibular ligament, anterior ligament of malleus

Second Reicherts cartilage

facial nerve

Stapes, styloid process, lesser cornu of hyoid, upper hyoid body auricle greater cornu of hyoid, lower part of hyoid body cricothyroid, levator veli palatini, palatopharyngeus, palatoglossus

stylohyoid ligament

Third Fourth

glossopharyngeal superior laryngeal branch of vagus recurrent laryngeal branch of vagus

Fifth, Sixth

intrinsic muscles larynx (except cricothyroid, stylopharyngeus), striated muscle of esophagus

Auricle develops from 1st and 2nd branchial arches o anterior hillocks: tragus, root of helix, superior helix (1st) o posterior hillocks: antihelix, antitragus, lobule (2nd) External auditory meatus develops from dorsal aspect of first branchial groove 1st pharyngeal pouch middle ear and Eustachian tube 3rd pharyngeal pouch inf parathyroid glands 4th pharyngeal pouch sup parathyroid glands

Anatomy

Bones optic nerve passes through lesser wing of sphenoid greater wing of sphenoid contains superior orbital fissure outer rim orbit= frontal, maxilla, zygoma, ethmoid Nerves Innervation of ear (CN V, IX, X) Superolateral ear, superior helix, superior external auditory canal, tragus: auriculotemporal nerve (V3) Concha: facial, tympanic branch of glossopharyngeal (IX), auricular branch of vagus (X) Lower half of ear: great auricular nerve (C2,3) Concha and antihelix: auricular branch of X helix and lobule: great auricular nerve and lesser occipital nerve (C2,3) Great auricular nerve emerges from behind sternocleidomastoid 9 cm below caudal edge of ext auditory canal, 6 cm inf to tragus; lies posterior and superficial to SMAS and platysma Sensation to lips infraorbital, mental, buccal (commissure) branch of V3 Innervation of tongue Vagus (X) : palatoglossus (only tongue muscle innervated by vagus) Hypoglossal (XII): chondroglossus, genioglossus, hyoglossus, styloglossus sensation anterior 2/3 of tongue is via lingual nerve (V), posterior 1/3 glossopharyngeal (IX) hypoglossal nerve is at risk during surgery for branchial cleft sinus or fistula o runs lateral to internal and ext carotid arteries, between ICA and IJ taste: anterior 2/3 chorda tympani (CN VII), posterior 1/3 CN (IX) lingual nerve also carries parasympathetics to the submandibular gland Blood supply to tongue is in ventral third from lingual artery Sensory innervation of maxillary alveolus: Nasopalatine nerve: palate Ant sup alveolar nerve:incisors, canines Middle sup alveolar nerve: bicuspids Post sup alveolar nerve: 1st, 2nd, 3rd molars Innervation of digastric: anterior belly digastric: inf alveolar nerve (V3) posterior belly digastric: CN VII Anterior belly can be transferred for marginal mandibular nerve paralysis Trigeminal nerve V1: sensation to forehead, anterior scalp V2: sensation to cheek, upper lip, upper teeth (superior alveolar nerve) V3: motor branches of buccal, masseteric, mandibular innervate temporalis o Branches of V2: infraorbital, nasopalatine, posterosuperior alveolar, posterosuperior nasal o Branches of V3: lingual, inf alveolar, long buccal, mental, auriculotemporal

V3 innervates sensory and motor: temporalis, masseter, pterygoids, mylohyoid, tensor tympani, anterior belly digastric, tensor veli palatine o Tensor veli palatine tenses soft palate and opens Eustachian tube during swallowing mental nerve exits foramen below apex of mandibular 2nd premolar (bicuspid) halfway down mandible

Facial Nerve transection of cervical branch of facial nerve loss of function of platysma, retracts and depress mandible marginal mandibular nerve innervates lip depressor muscle identifying facial nerve during parotidectomy: 1. use tympnomastoid suture (line between posterior bony auditory canal and mastoid), nerve is 6-8 mm deep to inf end of suture line 2. tragal pointer: medial end of tragal cartlage, nerve is 1 cm deep and anteroinferior to pointer Muscles

Orbicularis oris purses lips 7 occular muscles (origins) o levator palpebrae superioris (lesser wing sphenoid) o superior oblique (annulus tendineus communis)

superior oblique depresses, innervated by trochlear nerve o inferior obliques (maxilla)

o superior, inferior, medial, lateral recti (annulus tendineus communis)

Muscles involved in velopharyngeal closure: o levator palatini o palatopharyngeus o superior pharyngeal constrictors o uvulus Levator Veli palatini: Vagus nerve (also pharyngeal constrictors, musculus uvulae, palatoglossus, palatopharyngeus) o Levator veli palatini elevates soft palate and opens Eustachian tube o Palatoglossus elevates posterior tongue and pulls it against soft palate, closes off oral cavity from oropharynx o Palatopharyngeus: tenses soft palate pulling walls of pharynx superiorly, medially, anteriorly closing off nasopharynx from oropharynx o Musculus uvula pulls uvula superiorly and shortens it o derived from 4th branchial arch Tensor veli palatini derived from 1st branchial arch, innervated by Trigeminal (V) nerve o Tensor veli palatine courses around pterygoid hamulus (pulley) Stylohyoid derived from 2nd branchial arch, innervated by facial nerve (VII) Stylopharyngeus derived from 3rd branchial arch, innervated by glossopharyngeal nerve (IX) SCM has 3 equally dominant blood supplies: o upper third: occipital artery o middle third: superior thyroid o inf third: thyrocervical trunk Muscles that move mandible: o Medial pterygoid: elevates mandible, pulls it medially o Digastric: pulls anterior mandible posteroinferiorly o Buccinator: flattens cheek against teeth, does not exert force on mandible o Lateral pterygoid: protrudes mandible, pulls condylar head antermedially, only muscle that opens mouth

Muscles of mastication: lateral and medial pterygoids, masseter, temporalis (all innervated by V3) Anterior muscles of mandible depress mandible: Geniohyoid, genioglossus, mylohyoid, digastric o Geniohyoid, genioglossus, ant belly digastric pull downward and posteriorly if bilateral parasymphyseal fx Posterior muscles of mandible elevate mandible: Masseter, temporalis, medial and lateral pterygoid o Medial pterygoid: pulls upward, medially, forward o Lateral pterygoid: Upper head pulls upward medially and forward Lower head pulls downward, medially and forward o Masseter pulls upward o Temporalis: elevates and retracts mandible in ZMC fracture masseter pulls zygoma inferiorly simultaneous contraction of medial and lateral pterygoids produces side-side grinding of mandible Masseter: arises from lower border and medial surface of z arch, attaches to lateral ramus, elevates mandible Temporalis: originates in temporal fossa, attaches to coronoid process, retracts mandible

Arteries/blood supply Branches of external carotid from proximal to distal: superior thyroid, ascending pharyngeal, lingual, occipital, facial, posterior auricular, maxillary Internal carotid supplies supra-orbital and supratrochlear arteries (ophthalmic artery) Facial artery musculomucosal flap includes the buccinator muscle submental myocutaneous flap blood supply from submental artery which is branch of facial artery Blood supply to temporalis flap: deep temporal artery Juri flap blood supply = superficial temporal artery blood supply to tongue is in ventral third, from lingual artery Other meibomian and lacrimal glands innervated by lacrimal nerve (from ophthalmic division of trigeminal V1) Lymphatic drainage retromolar trigone, posterior gingival, tonsil and post 1/3 tongue cancers go to jugular digastric (level II) nodes, then midjugular (III), then lower jugular (IV) anterior floor of mouth, ant 2/3 tongue, lip, cheek go to submandibular and submental (I) cervical nodes most commonly metastatic from nasopharynx Duct Drainage: Nasolacrimal duct drains into inferior meatus beneath inf concha Anterior ethmoid air cells, maxillary sinus, frontal sinus (via frontonasal duct) drain into middle meatus Sphenoid sinus drains into sphenoethmoid recess Foramena: Foramen Bones Structures Superior orbital fissure Greater, lesser wing sphenoid, Ophthalmic division of trigeminal

frontal

Rotundum Ovale Jugulare Spinosum Lacerum Optic Inferior orbital fissure Pterygomaxillary fissure

Greater wing sphenoid Greater wing sphenoid Temporal and occipital Sphenoid Sphenoid and temporal Lesser wing sphenoid Greater wing sphenoid, maxilla Greater wing sphenoid, maxilla

(V1) nasociliary, lacrimal, frontal branches, oculomotor nerve (III), trochlear nerve (IV), abducens (VI), sympathetic fibers maxillary division of trigeminal (V2), located in sphenoid bone in middle cranial fossa mandibular division of trigeminal (V3), accessory meningeal art. glossopharyngeal (IX), vagus (X), accessory (XI), IJ Middle meningeal art and vein, meningeal branch of mandibular nerve Internal carotid optic nerve (II), ophthalmic artery maxillary and zygomatic nerves and infraorbital vessels maxillary artery, vein

Intra-cranial communication of frontonasal encephalocele through foramen cecum The Ear

helical root arises from concha then divides into cymba and cavum antihelix is curved prominence parallel to helix triangular fossa: concave area between superior and inf crura scaphoid fossa: groove between helix and antihelix

Craniosynostosis Type of synostosis plagiocephaly

Sutures involved unilateral coronal suture fused

Characteristics - harlequin orbit from elevation of lesser wing of sphenoid - ipsilateral forehead flattened, brow contralateral forehead bossing - superolateral orbit elevated

Surgery Fronto-orbital advancement

brachycephaly turribrachycephaly trigonocephaly

fusion of both coronal sutures extending into cranial base bilateral coronal fusion synostosis of metopic suture

and retruded - ipsilateral superior oblique paresis 2ndary to foreshortening of orbital roof - deviation of root of nose toward affected suture - most commonly assoc w/ FGFR3 mutation excessive wide and retruded anterior cranial vault shortened, wide skull w/ incr vertical height at top of skull triangular shaped deformity of forehead, orbital hypotelorism, growth inhibited perpendicular to synostosis, prominent midline ridge in forehead - associated w/ abnormalities of corpus callosum and developmental delay elongated, narrow skull **Most common nonsyndromic single-suture craniosynostosis retrusion of frontal bone and ear on affected side, flattening of occiput, trapezoid shape doesnt result in abnormal shape

Bilateral frontoorbital advancement, if severe total cranial vault remodelling Removal of supraorbital bar w/ posterior corticotomy along synostosed metopic suture, bone flattened to restore forehead contour, may need correction of hypotelorism

scaphocephaly

synostosis of sagittal suture

strip craniectomy to total calavarial remodeling, barrel stave osteotomies; sagital sinus lies deep to sagittal suture

Lambdoid synostosis

squamosal suture

Syndromic synostosis

Early intervention may require only strip craniectomy, if > 6 mo, requires reshaping posterior cranial vault Extensive surgical intervention, frontoorbital advancement w/ later Lefort III, or monobloc advancement; distraction osteogenesis increasingly applied

Deformational plagiocephaly: frontal bossing and anterior displacement of ear, flattening of occiput, parallelogram shape premature fusion of metopic suture, Unicoronal synostosis, and syndromic craniosynostosis (Pfeiffer, Apert, Crouzon, Jackson-Weiss) assoc w/ mutation in FGFR-3 FGFR most commonly assoc w/ unicoronal synostosis (chrom 4p16) TGF and b-FGF assoc w/ premature fusion of sutures anterior fontanelle closes between 18-24 months posterior fontanelle closes at 2 months Hypotelorism: trigonocephaly, holoprosencephaly (breakdown of formation of prechordal mesoderm) Hypertelorism: frontonasal encephalocele, frontonasal dysplasia, Aperts & Crouzon syndromes

Craniosynostosis syndrome 1. Apert syndrome: sporadic, turribrachycephaly, midface hypoplasia and hypotelorism, bony syndactyly and coalition of digits, submucosal cleft, facial acne 2. Crouzon syndrome: a. autosomal dominant, b. craniosynostosis of coronal, sagital, lamdoid sutures c. turribrachycephaly: short AP skull dimension, wide transverse dimension, increased projection of superior skull d. midface hypoplasia, exorbitism, proptosis e. fingers & toes unaffected f. mutation FGFR2, chromosome 10 3. Pfeiffer syndrome: dominant, enlarged bulbous thumbs and halluces + craniofacial features of Apert and Crouzon , Class III occlusion 4. Saethre-Chotzen: auto.dominant, craniosynostosis, low hairline, low frontal hairline w/ backward sloping forehead, low-set ears, beaking of nose, ptosis of eyelids, simple syndactyly brachydactly (short stubby fingers), maxillary hypopolasia, mutation in TWIST gene 5. Carpenter syndrome (acrocephalopolysyndactyly): auto recessive, craniosynostosis, flat nasal bridge, low set ears, abnormal globe and canthi, brachydactyly, congenital heart disease, hypogenitalism, obesity, umbilical hernia 6. Jackson-Weiss syndrome : dominant, craniosynostosis, broad halluces, fusion of tarsal and metatarsal bones

Other Craniofacial Syndromes 1. Craniofacial microsomia: 1 in 5600, CN VII most common involved, mandibular hypoplasia, microtia, macrostomia, hypoplastic muscles of face, VPI, orbital dystopia, epibulbar dermoids, cleft lip, palate, plagiocephaly a) **most common craniofacial anomaly is hemifacial microsomia b) isnt genetically transmitted c) sequence of repair: macrostomia, mandibular deformity, maxillary deformity, soft tissue repair is last 2. Velocardiofacial syndrome (Shprintzen syndrome): a) autosomal dominant b) deletion chromosome 22q c) **most common syndrome assoc w/ cleft lip and palate d) submucous cleft, hypernasality and VPI e) developmental delay f) facial abnormalities: narrow palpebral fissures, vertical maxillary excess, malar flattening, mandibular retrognathia, prominent nose w/ square nasal root, narrow alar base g) microcephaly (40-50%) h) cardiac anomalies in >80% (VSD) i) absent thymus and parathyroids j) ectopic carotid arteries superficial within posterior pharyngeal wall 3. Pierre Robin: microretrognathia, glossoptosis, respiratory distress +/- cleft palate (50%) Initially manage airway obstruction w/ prone positioning 4. Sticklers : eyes (myopia, retinal detachment, progressive blindness, cataracts) assoc Pierre Robin 5. Klippel-Fiel anomaly = short neck, low posterior hairline, deformities of cervical spine, facial abnormalities, hearing loss, cleft palate 6. Binders syndrome: a) Maxillonasal dysplasia b) Shortened nose, flattening of nasal bridge, perialar regions c) Columella shortened, nasolabial angle acute, upper lip convex d) anterior nasal spine and frontonasal angle absent (pathognomonic) e) Angle class III occlusion f) Hypoplasia of anterior nasal floor g) Primary goal of surgery is increasing length of nose and projection of nasal tip h) Le Fort I or II osteotomy and orthodontics 7. Gorlin syndrome: autosomal dominant, multiple basal cell carcinomas, odontogenic keratocysts, skeletal anomalies, calc of falc ceribri, nasal deformities, palmar and plantar pits 8. Osler-Weber-Rendu hereditary hemorrhagic telangiectasia (esp lips) 9. Albright syndrome: polyostotic fibrous dysplasia (maxilla, femur, tibia; higher risk for osteosarcoma) and pigmented cutaneous lesions; sexual precocity in females, premature closure of epiphyses, rudimentary kidneys, coarctation of aorta, endocrine abnormalities 10. Nagers syndrome (craniofacial and radial deficiency): a) autosomal recessive b) acrofacial dysostosis, craniofacial and upper extremity abnormalities c) hypoplasia or agenesis of thumbs, radius, one or more metacarpals d) hypoplastic orbits, zygoma, maxilla, mandible, soft palate, cleft palate e) short stature 11. Treacher Collins syndrome: a) Mandibulofacial dysostosis b) Tessier No 6,7,8 clefts i) colobomas of lower eyelids, absence of eyelids (6) ii) absence of malar bone and zygomatic arch, microtia, hypoplasia of temporalis, low hairline (7) iii) displacement of lateral canthi (8)

c) d) e) f) g) h)

12. 13. 14. 15.

Orbit is oval on CT Inf orbital rim, lateral orbital wall, orbital floor underdeveloped Malar hypoplasia Micrognathia, hypoplastic condyle Chin dysplastic, vertically long and retrusive Obtuse gonial angle i) Angle class II occlusion Goldenhars syndrome: oculoauriculovertebral dysplasia, asymmetry of hard and soft tissues of face; hypoplasia of mandible, epibulbar dermoids, microtia, vertebral abnormalities Van der Woude: recessive, cleft lip, palate, lip pits Mobius syndrome: facial nerve palsy, strabismus, syndactyly Romberg disease: a) hemifacial atrophy, ipsilateral neck, trunk, and/or extremities b) manifests in childhood and resolves spontaneously by adulthood c) progressive atrophy of skin, muscle, bone, cartilage on one side of face d) can present as progressive painless enophthalmos e) microvascular parascapular flap reconstruction when atrophy stops

More Congenital Craniofacial port wine stain of face capillary vascular malformation, corresponds to distribution of V1, V2 nerves; incr risk for Sturge-Weber, motor seizures, hemiparesis, vision abnormalities (glaucoma and buphthalmos), mental retardation, leptomeningeal venous malformations initial treatment for rapidly enlarging hemangioma obstructing visual axis oral steroids microtia should undergo autologous ear recon age 7 when ear is developed o defect includes auditory ossicles, ext auditory canal, middle ear cavity, tympanic membrane o NOT cochlea o 1st branchial arch, 1st trimester Ear Deformities o cryptotia: upper pole of ear buried beneath scalp, superior auriculocephalic sulcus absent o cup ear deformity: hooding of scapha and helix, flattening of antihelix o lop ear: protrusion and folding of superior helix o prominent ear deformity: widening of conchoscaphal angle, incr auriculocephalic distance, loss of antihelical fold o Stahl ear: 3rd crus Effacement of superior crus causes prominent superior third of ear, conchoscaphal angle > 90 deg, helix > 12-15mm from temporal region, cephaloauricular angle > 25 deg prominent middle third of ear caused by hypertrophy of concha cavum aplasia cutis congenital: scalp defect in midline of vertex; may be assoc w/ skull defect and/or exposure of brain; most close spontaneously o manage initially with frequent silvadene dressing changes torticollis: shortening of SCM w/ deviation of chin up and contralateral to affected muscle, assoc w/ nonsynostotic or deformational plagiocephaly Encephalocele: herniation of cranial tissue through skull defect, soft, bluish, compressible, pulsatile, located at nasal root, transilluminate, enlarge w/ crying and Valsalva fibrous dysplasia: rare condition of bone, can cause sx by displacing orbit and globe

Orthognathic 1. SNA = 82 +/- 3 degrees; relates maxilla to cranial base in horizontal plane 2. SNB= 80 +/- 3 degrees; relates mandible to cranial base, smaller in hypoplastic mandible, more obtuse in prognathism 3. ANB: relationship of maxilla to mandible in horizontal plane (more obtuse in hypoplastic mandible, positive in maxillary protrusion, mandibular retrusion) 4. SNO: relates orbit to cranial base

5. 6.

SNPg = 80; pogonion (Pg) is anterior most chin point, measures degree of chin prominence ANS-Me: measures height of lower face, increased in long face syndrome

Frankfort horizontal: passes through porion (tragion) and orbitale Maxillary hypoplasia: SNA < SNB, ANB < 0 Maxillary retrusion is most common cause of decreased SNA angle with normal SNB angle Mandibular deficiency: SNB angle decr Mandibular excess: wide lower 1/3 face, anterior crossbite , Angle class III, SNB angle incr Mandibular prognathism a. Class III occlusion b. Increased SNB angle c. Negative ANB angle d. Excessive protrusion of mandible in relation to maxilla e. Rx: sagital split osteotomy and maxillary advancement

Angle classification:

Based on mesiobuccal cusp of maxillary and mandibular first molars Class I occlusion (neutral occlusion): mesiobuccal cusp maxillary first molar lies in buccal groove of mandibular 1st molar Class II malocclusion: mesiobuccal cusp of maxillary 1st molar anterior to buccal groove of mandibular 1st molar o Division 1: lateral incisiors flared labially

Division 2: incisors lingually inclined; retrognathic appearance

Class III (mesio-occlusion): mesiobuccal cusp maxillary 1st molar distal or posterior to buccal groove of mandibular 1st molar Angle III and malar hypoplasia should undergo Le Fort I maxillary osteotomy w/ advancement and vertical lengthening

Crossbite = position of mandibular and maxillary molars in transverse plane 2nd most common cause of crossbite is absence of permament lateral incisor Seen in unrepaired alveolar cleft w/ cleft lip Overbite = distance between maxillary and mandibular incisors in vertical plane w/ jaws in centric occlusion; upper central incisor overrides lower central incisor in vertical dimension Overjet = distance btwn maxillary and mandibular incisors in horizontal plane w/ jaws in centric occlusion; upper central incisors lies anterior to lower central incisor in sagital plane Tooth eruptions: 1. Permanent 1st molars: age 6-7 (1st molar is 1st permanent tooth to erupt) 2. Central and lateral incisors: age 6-8 3. First premolars: age 8-9 4. Permanent canines: age 10-11

Normal incisor show at rest = 2-3 mm; at full smile 1-2 mm gingival show o no incisor show at rest is sign of vertical maxillary deficiency Vertical maxillary deficiency: 1. decreased facial height 2. absence of maxillary incisor show 3. upper lip short and flat 4. edentulous appearance 5. wide alar base 6. acute mandibular plane angle 7. SNB angle normal or larger 8. Rx: Lefort I osteotomy w/ inferior repositioning of maxilla Excessive gingival show is sign of vertical maxillary excess Vertical maxillary excess (long face syndrome); 1. gummy smile long face 2. Incr height of lower 1/3 face 3. Labial incompetence w/ lips in repose 4. excessive interlabial gap 5. retruded chin 6. Excessive incisal show 7. Lip-to-tooth relationship > 3mm 8. Mentalis strain 9. Obtuse nasolabial angle 10. Narrow alar base 11. Retrognathiic mandible, Angle class II occlusion 12. Treat w/ Le Fort I osteotomy w/ maxillary impaction +/- osseous genioplasty i) Decreases mentalis strain ii) More acute nasolabial angle iii) Forward autorotation of mandible counterclockwise iv) Alar base widens

Genioplasty

sliding genioplasty moves chin forward to reduce sagital deficiency and moves chin down increasing lower anterior facial height and effacement of labiomental fold can change vertical height, either elongate or shorten advancement genioplasty blood supply from posterior muscle attachments In pts w/ vertical mandibular excess and retrogenia, advancement with osteotomy angled inferiorly will both reduce vertical height and increase projection Alloplastic chin aug is best for minimal sagital deficiency of lower face, shallow labiomental fold, symmetric and normal height of lower face; not appropriate for chin asymmetry

Le Fort I Osteotomy Lefort I osteotomy w/ maxillary impaction for decreased maxillary height In Le Fort I ostetomy, final vertical position of maxilla determined by maxillary lip-tooth relationship Placement of alar cinch suture during Le Fort I osteotomy can decrease widening of alar base after exposure of anterior maxilla blood supply to maxilla after LeFort I: ascending palatine branch of facial art, palatine branch of ascending pharyngeal art (both are branches of ext. carotid) normal blood supply to maxilla: descending palatine, posterior superior alveolar, infraorbital (internal maxillary art) o hard palate: descending palatine (greater palatine branch), sphenopalatine (nasopalatine branch) o soft palate: ascending palatine art (facial art) artery frequently injured during Le Fort I: descending palatine Osteotomies in Le Fort I: o Anterior antral walls o Lateral antral walls o Pterygoid plates bilaterally o Midpalatal suture o Nasal septum o Vomer o Across base of maxillary sinus and floor of piriform aperture midface hypoplasia secondary to repaired cleft palate are increased risk for developing VPI esp after Le Fort I Most common changes after Le Fort I maxillary advancement: 1. Increased nasolabial angle 2. Widened alar base 3. Upper lip shortened 4. Incisal show increased LeFort I > 10mm is unpredictable, use distraction osteogenesis > 5mm use bone grafts open bite after Le Fort I fx fixation means fracture site not adequately disimpacted cuspid or canine has longest root, most likely injured in Le Fort I highest risk for postop VPI is h/o cleft palate Lefort Osteotomies 1. Lefort I osteotomy: midface advancement, osteotomy at level above apices of teeth, alveolar process of maxilla, vault of palate and pterygoid process included, ostetomy across base of maxillary sinus and floor of piriform aperture 2. Lefort II osteotomy: level of apices of teeth laterally, extends through plates (like

3.

Lefort I), includes medial obital wall, orbital floor, nasofrontal junction; incr risk of injury to ethmoid area and lacrimal system, not lateral orbital wall Lefort III: extends through zygomaticofrontal suture and nasofrontal suture and across medial orbital wall & obital floor; pterygomaxillary disjunction performed entire midface detached from face; if > 10 mm, distraction osteogenesis, not bone grafting produces more stable result 5. monobloc advancement: osteotomy lines similar to LeFort III, but nasofrontal junction and frontozygomatic suture arent osteotomized; advantage is simultaneous correction of supraorbital and midface deformities; assoc w/ higher rates of infection, CSF leakage 6. Transverse maxillary widening is the most unstable orthognatic movement

Distraction osteogenesis principles: Minimal disruption of central medullary bone Low energy corticotomy Increased fixator stability Preservation of periosseous and intraosseous soft tissues Distraction osteogenesis of mandible Stable bone fixation is most important Consolidation period of 4-6 wks before removal of devices Distraction rate 1-2mm/day Lag period not needed latency period between osteotomy and distraction in children is 5-7 days Supraperiosteal dissection not necessary Mandibular distraction osteogenesis in < 2 yo only when tongue based airway compromise Distraction osteogenesis central region of distraction gap is called fibrous zone o Transitional zone adjacent contains fibrous tissue undergoing ossification o Zone of remodeling bone, then zone of mature bone Advantage of rigid external distraction (RED) - need for fewer operations (can be removed in clinic) Most common complication of sagital split osteotomy is loss of lower lip sensation 85-97% incidence immediate postop Risk of permanent damage to inferior alveolar (mental) nerve during sagital split osteotomy is 510% in juvenile RA, orthognatic procedures should not increase loading on TMJ, mandibular deficiency should be corrected w/ maxillary impaction, not sagital split osteotomy Bone healing Bone defects > 5mm in craniofacial skeleton should be bone grafted Osteogenesis: formation of new bone by cells in the graft that havent died vascularized bone grafts osteoinduction: bone morphogenetic protein induces transformation of perivascular mesenchymelike cells into osteoprogenitors Bone graft w/ greatest inductive capacity: autologous cancellous due to BMP demineralized bone graft, cadaveric bone also inductive first cells to appear are chondroblasts first 5 days osteoblasts appear POD 9 All non-vascularized bone grafts undergo resoprtion and remodeling (creeping substitution) and have inductive capacity (stimulate new bone formation) osteoconduction (creeping substitution): tissue ingrowth from host recipient bed into grafted material eg corical bone grafts like cranial bone graft cancellous bone grafts (eg iliac crest) heal by osteoconduction and osteogenesis endochondral ossification: new bone within hyaline cartilage framework membranous ossification: condensation of mesenchymal tissue, eg cranial vault, face

bone grafts should be stored in blood soaked sponge Heterotopic ossification: abnormal proliferation of bone, treated w/ etidronate, pamidronate which inhibit formation, growth and dissolution of hydroxyapatite crystals Hydroxyapatite cement: osteoconductive (encourages peripheral ingrowth of new bone) Wolffs law: stress needed to preserve strength and volume of grafted bone

Head & Neck Tumors

rhynophyma rx: tangential excision, 3-10% incidence skin cancer lymphangioma: clear or hemorrhagic vesicles on tongue surgery for hemangioma: airway obstruction, bleeding and ulceration, Kasabach-Merritt syndrome, visual obstruction DDx of midline nasal mass in child: dermoid cyst, encephalocele, glioma infant w/ mass over dorsum of nose is most likely an extranasal glioma Nasal glioma: firm, reddish, noncompressible, non-pulsatile, doesnt transilluminate or change w/ Valsalva, + overlying telangectasia

Tumors of mandible unicystic ameloblastoma of mandible o benign tumor o palisading, columnar, deep-staining cells (ameloblasts) o rx segmental resection and reconstruction o can degenerate into ameloblastic fibrosarcoma giant cell tumor o most common benign tumor of facial skeleton in kids o radiolucent, well defined margins o Indistinguishable from brown tumors of hyperparathyroidism o Small tumors curettage, large tumors resect and reconstruct Fibrous dysplasia o Disorganized connective tissue stroma, partially calcified osteoid Odontoma (Hamartoma) o Benign odontogenic tumors o Complex (contains all dental components) vs compound (only contains rudimentary teeth) o Posterior mandible most common location o Enucleation Cementoblastoma o Rare odontogenic tumor o Radioopaque o Develops in mandibular 1st molar and expands into cortex causing pain o Rx w/ endodontics and periapical surgical excision Dentigerous cyst o Lined w/ epithelium o Typical location mandibular 3rd molar o enucleation Keratocyst o Lined w/ keratinized stratified squamous epithelium o Locally aggressive Dermoid cysts: develop along embryonic cleft lines in head and neck, lateral eyebrow, midline nasal root, neck; nasal pit is characteristic if midline, get CT to determine intracranial extension

dermoids w/ indistinct margins and proptosis w/ pressure may have extension through lateral orbital wall: get CT scan 10-45 % of nasoglabellar dermoid cysts have intracranial extension radiation for primary nasopharyngeal cancer Osteoradionecrosis: risk incr w/ > 6500 Gy, dental caries and extraction sites

Staging of Head & Neck cancers

squamous cell carcinoma:

o desmosomes, intercellular bridging, frequent mitoses, pleomorphism, keratin pearls o most common site of SCC in paranasal region = maxillary sinus
o tongue is most common site of SCC in oral cavity o Nickel is assoc w/ SCC of nasal sinus cavity Lymphatic drainage: o Oropharynx, hypopharynx, larynx subdigastric, midjugular, lower jugular lymph nodes o Buccal mucosa, floor of mouth submandibular triangle, subdigastric, midjugular o Lip submandibular, submental o Temporal cutaneous parotid T4 SCC of base of tongue requires laryngectomy if it invades hypopharynx dermatofibrosarcoma protuberans o low-intermediate grade sarcoma o aggressive, local recurrence rate 60% difficult to get margins in head and neck o 14% in head & neck o Rx: resection w/ 3 cm margins +/- Mohs Chondrodermatitis nodularis helicis chronica o Perforating collagenosis o > age 50 o Painful o From minor trauma o Path: degenerated dermal collagen, chronic lymphocytic infiltrate, fibrous thickening of perichondrium o Rx: topical or intralesional steroids

Parotid Stensons duct (parotid) o opposite maxillary 2nd molar o travels w/ buccal branch of facial nerve o within the buccal space bordered

anteriorly by orbicularis oris posteriorly by edge of masseter superiorly by zygomaticus major inf by fascial attachements of buccinator

Warthin tumor o benign neoplasm of parotid o 10% bilateral o no pain or weakness of face o most common neoplasm of parotid Most common malignancy of parotid (and salivary glands overall) = mucoepidermoid carcinoma o Low grade: slow growing, indolent o High grade: higher recurrence rate, facial nerve invasion Adenoid cystic carcinoma (aka cylindroma) most aggressive and assoc w/ metastatic dz (lungs, liver, bone)

classically perineural spread most common malignancy outside of parotid most commonly occurs in submandibular gland infrequent in parotid Pleomorphic adenoma of parotid: o 80% of all benign parotid tumors o 65% of all salivary masses o 55% of parotid masses o 90% in superficial lobe o Luminal-type ductal cells w/ mixed sheets of myoepithelial cells and mucoid extracellular matrix o Rx is superficial parotidectomy w/ facial nerve preservation o multinodular local tumor is most common recurrence, rx w/ radical resection and radiation Parotid tumors o Basal cell adenoma: MC monomorphic adenoma found in minor salivary glands of upper lip, rows of palisading cells w/ thickened basement membrane o Myoepithelioma: rare, benign, from myoepithelial cells, spindle cells o Warthins tumor (papillary cystadema lymphomatosum): slow growing multicystic mass, men age 40-70, papillary epithelium w/ lymphoid stroma projecting into cystic spaces; 10% of parotid tumors, 10% multicentric, 10% bilateral Most common parotid tumor in childhood: hemangioma Salivary gland hemangiomas: 90% parotid, 10% minor salivary, sublingual or submandibular Auriculotemporal nerve innervates parotid gland o Frey syndrome after parotidectomy: injury of auriculotemporal nerve (V3), dermal sweat glands reinnervated abnormally by parasympathetics from auriculotemporal nerve o Can treat w/ Botox most common site of minor salivary malignancy is palate most common met to parotid = melanoma

Facial Fractures Superior orbital fissure syndrome: Symptoms: diplopia, ophthalmoplegia, numbness of forehead, proptosis CN III (levator, superior recuts, inf rectus, inf oblique) IV (trochlear: superior oblique) V1 (anesthesia of brow, upper lid, forehead) VI (abducens: lateral rectus) Orbital apex syndrome = superior orbital fissure + blindness NOE fractures Physical findings: o deep nasofrontal angle, epiphora, telecanthus, upturning of nasal tip; Not mobile maxilla o impaction of nasal bridge w/ shortening of nose, hematomas of eyelids o Blunting of canthal angle, movement of canthus when eyelid pulled laterally

extensive comminution of medial orbital wall, ethmoid sinus, bony and cartilaginous structure of nose Rx ORIF w/ plates, screws through coronal approach; cantilever bone graft prevents loss of support Types o Type I simple fx of central segment o Type II comminution of central segment, o Type III avulsion of attachment of medial canthal tendon In NOE fractures, observe lacrimal system (90% have improvement of sx w/ resolution of swelling) o Unless obviously injured o If nasolacrimal duct occluded post-op, dacrocystorhinostomy is indicated

Le Fort Fractures Le Fort I: transverse fx separating maxillary alveolus from superior midfacial skeleton o fx line above maxillary teeth, across pyriform aperture, involves pterygoid plates o movement of lower maxilla, but not at nasal root

Le Fort II: pyramidal fx separating central nasomaxillary segment from zygomatic and lateral upper midfacial skeleton o midportion of fx crosses nasofrontal area including medial infraorbital rims o anesthesia of cheek, step deformity at infraorbital rim, bilateral circumorbital & subconjunctival ecchymosis, lengthening of face and malocclusion Le Fort III: craniofacial disjunction, involves sepration at frontozygomatic suture, nasofrontal junction, medial orbital walls, orbital floors, zygomatic arches laterally o maxilla is intact o movement at lateral orbital rim **Le Fort fractures change vertical height, but not width Frontal Sinus Fractures Frontal sinus: o viewed radiographically at age 6 yrs, supplied by supratrochlear and supraorbital arteries (from ophthalmic artery) o frontal sinus drains into middle meatus

Comminuted posterior wall frontal sinus fx: cranialization or sinus obliteration Non-displaced posterior wall + CSF leak: initially observation for 5-7 days Anterior table blocking nasofrontal duct rx: surgical removal of all sinus mucosa, plugging of nasofrontal ducts w/ bone grafts, elevation of fracture of ant table w/ rigid fixation Mucocele after fracture: exenteration of mucosa and obliteration of sinus and nasofrontal ducts long term complications of frontal sinus fx: osteo, mucocele, chronic intracranial or orbital abscess, cosmetic deformity cyanoacrylate glues provide compressive forces similar to plates & screws

ZMC Pt w/ enophthalmos and widened midface has ZMC fracture ZMC fracture fixation: o zygomaticofrontal suture, inferior orbital rim, zygomaticomaxillary buttress o most useful landmark in restoring zygoma to anatomic position is lateral orbital wall (zygomaticosphenoid articulation, zygoma and greater wing of sphenoid) o Most displaced zygomatic fractures are depressed and rotated laterally, palpebral fissure is pulled downward Gillies approach to zygomatic arch fx: elevator goes between deep temporal fascia and temporalis muscle; desired position beneath malar eminence and zygomatic arch Most common cause of enophthalmos after ZMC or orbital floor fx fixation is inadequate reduction of fracture fragments ptosis of malar fat pad can occur after ORIF of zygomatic fx causing facial asymmetry o decreased projection of cheekbone o fullness of nasolabial fold o prevented by resuspending periosteum internal fixation for midface fractures maintains facial height downward cant of palpebral fissure Bones of orbit medial orbital wall is mostly orbital plate of the ethmoid bone orbital floor = maxilla medially, zygoma anteriorly lateral orbital wall: zygoma, greater wing of sphenoid other bones comprising orbit: ethomoid, frontal, lacrimal, maxilla, palatine, lesser wing of sphenoid

lacrimal groove is composed of lacrimal bone and maxilla Orbital blowout fx diplopia most commonly from edema if forced duction is negative numbness of cheek skin is due to injured infra-orbital nerve within orbital floor enophthalmos due to increased bony intraorbital volume Transconjunctival preseptal incision for ortibal floor fractures: incision capsulopalpebral fascia and dissection plane is between orbicularis oculi and septum Fixed dilated pupil after ORIF of orbit is likely due to injury of ocular parsympathetic nerves that travel w/ oculomotor nerve and inferior oblique muscle Marcus-Gunn pupil is afferent papillary defect: direct response to light impaired, but consensual response is preserved Medial orbital wall fx o Enopthalmos o Ipsilateral epistaxis o Subcutaneous emphysema o Includes fx of lateral component of ethmoid sinus Initial management of ectropion after repair of orbital blowout fx is lubrication and massage of eyelid for 6 months If > 6 mo, surgical options: Kuhnt-Szymanowski procedure (horizontal shortening of lower lid) lateral canthoplasty release of scar tissue and application of Frost suture nasal septal cartilage graft to support posterior lamella lateral canthoplasty in man, periosteal fixation should be at level of upper pupil retrobulbar hematoma causing blindiness: pain, exophthalmos, ecchymosis of eyelid if vision normal, open incisions, evacuate hematoma, exploration of bleeding if vision changes, release septum orbitale and release lateral canthal tendon adjunctive rx: mannitol, acetazolamide, dexamehtasone, 95% oxygen/5% carbon dioxide mixture to reduce intraocular pressure Hyphema = traumatic hemorrhage of anterior chamber may cause incr ocular pressure rx acetazolamide, corticosteroid drops

Mandible incidence of cervical spine injury in mandible fractures is 5-15% mandibular fx (adult): angle>parasymphysis>body>condyle o in kids < 10, 66% involve condyle infections following ORIF of mandibular fx result from failure of fixation Rx for intraoral exposure of hardware is good oral hygiene and observation Champy principle: miniplates w/ monocortical screws along lines of tension in mandible at site of fracture o Anterior to canines 2 miniplates control rotational forces of genial and digastric muscles o Posterior to canines 1 plate Locking reconstruction plates o decrease post-op malocclusion in comminuted fx o decreased bone resorption o less difficulty contouring plate o no increase in hardware failure o same rate of hardware-related infection submandibular space o submandibular gland, lymph nodes, facial vein and art, inf loop of hypoglossal nerve

o
sublingual space o o

communicates w/ submental space (ant), pharyngeal space (post) infections of 2nd and 3rd mandibular molars can extend into it superomedial to mylohyoid anterior mandibular teeth infections drain into it Displacement into middle cranial fossa Lateral extracapsular displacement of condyle Impossibility of obtaining adequate dental occlusion by Invasion by foreign body (bullet)

Indications for open reduction of condylar fracture: o o o closed reduction o

Unilateral condyle fractures: upward cant of mandible ipsilateral ipsilateral premature contact of molars trismus ipsilateral loss of vertical height Bilateral condyle fractures bilateral loss of vertical height anterior open bite Condylar neck fractures Condylar fractures in children Lateral pterygoid muscle pulls condylar fragment medially Masseter, medial pterygoid, temporalis insert below neck

Intracapsular fractures only involving condylar head treat w/ Increased risk for ankylosis Condylar fx in peds treat w/ MMF for 10-14 days Immediate mobilization Examine weekly

immediate immobilization o

in child how has trauma to chin, r/o condylar fx pediatric condyle is primary growth center of mandible facial fractures in children: nasal (first) mandible (66% are of condyle, age < 10yrs) skull fx more common than facial Indications for extraction of teeth in line of fracture: o Displaced or comminuted fx containing tooth o Fracture of tooth or root structure o Periodontal dz of supporting structures o Functionless tooth in absence of opposing teeth Miscellanous non-displaced coronoid fx: place in MMF for 1-2 wks normal range of vertical mandibular opening: 40-50 mm measured from maxillary incisal edge to mandibular incisal edge + lateral jaw excursion 10 mm to each side first 1-2 cm is rotation in lower joint space final 3-5 cm is translation into upper joint space Fracture of mandibular body most likely to cause inferior alveolar nerve injury and numbness of lower lip Advantage of using plates & screws for midface fractures is maintenance of facial height

TMJ

TMJ clicking: o clicking sound of TMJ on opening jaw most likely subluxation of articular disk o operative correction only for internal derangement of TMJ assoc w/ congenital anomalies, neoplasia, trauma, pain or trismus o Options: intracapsular repositioning of disk, removal of disk, placement of temporalis fascia flap pain is mc sx of TMJ internal derangement chronic TMJ dislocations: maxillomandibular fixation, augmentation of articular eminence trauma is most common cause of TMJ ankylosis Treatment for ankylosis of TMJ: o Alloplastic interposition arthroplasty o Condylectomy o Costochondral graft arthroplasty o Gap arthroplasty Conditions predisposing to TMJ disorders Angle II Absence of posterior teeth Apertognathia Long face syndrome prognathism Myofascial pain dysfunction: assoc w/ preauricular pain, occasional joint clicking, restricted jaw opening, tenderness of masticatory muscles caused by bruxism, anxiety, occlusal abnormalities xrays normal Acute open lock deformity: Inability to close jaw Condyle slips into anterior position 1st step: attempt manual reduction under sedation in ER next, use succinylcholine in OR Progressive condylar resorption Late case of open bite in young women Condylar shortening Decreased posterior facial height Clockwise rotation of mandible Angle class II occlusion Slow progressive posterior movement of point B

Clefts Tessier Clefts: 0-7 =facial clefts, 8-14 =cranial extension, combination adds up to 14 No 1: lateral to midline, beginning at cupids bow and passing through dome of nostril lateral to anterior nasal spine, notching of alar dome is distinctive feature, hypertelorism, encephalocele No 2: rare, transition betwn 1 and 2 No 3: only cleft to involve nasal ala and medial canthus; displacement of medial canthus of eyelid, begins in alveolus btwn lateral incisor and canine, extends through maxilla into lacrimal bone, naso-ocular cleft, inferomedial wall of orbit is missing, shortening of nose, colobomas of nasal alae and lower eyelids medial to punctum, obstruction of nasolacrimal duct, malformation of lower canaliculus No 4: btwn piriform aperture and infraorbital foramen, begins lateral to cupids bow and philtrum and passes lateral to nasal ala and onto cheek, medial canthus unaffected o Osseous component of No 3 and 4 is between lateral incisor and canine No 5: begins behind canine, extends through maxillary sinus to orbital floor, colobomas of lower eyelid, clefting of upper lip medial to oral commissure

No 6: incomplete form of Treacher Collins, passes inferior and lateral to oral commissure toward angle of mandible, colobomas of lateral lower eyelids No 7: most common, 1 in 3000, sporadic transmission, zygomatic arch is absent, macrostomia No 8: extends from lateral commissure of palpebral fissure to temporal region, colobomas of lower eyelid No 9: supraorbital extension of No 5 Numbers usually add up to 14

Embyrology of Clefts 5 facial prominences: frontonasal, paired maxillary, paired mandibular i) unilateral cleft lip: incomplete fusion of medial nasal and maxillary nasal prominences on affected side primary cleft palate occurs from unsuccessful fusion of median palatine process and lateral palatine process secondary cleft palate occurs following unsuccessful fusion of lateral palatine processes to each other and with nasal septum nasal septum: fusion of medial nasal prominences macrostomia: unsuccessful fusion of maxillary and mandibular prominences Isolated cleft palate 1:2000 50% have assoc anomalies Cleft lip and palate 1:1000 Overall incidence 1:500 Asian 1:750 Caucasian 1:2000 Black 10-15% assoc anomalies Risk of subsequent cleft Person affected General population Normal parent + unilateral CL Normal parent + bilateral CL, no CP Normal parent + bilateral CL and CP Normal parent + 2 affected kids Affected parent + normal kid Affected parent + affected kid

Risk 0.1% 4% 6.7% 8% 9% 4% 17%

Cleft palate repair disrupts: nasal lining, levator veli palatini, tensor veli palatini, musculus uvulae, not palatopharyngeus Passavants ridge: bulge on posterior pharynx above arch of atlas caused by forceful contraction of superior pharyngeal constrictor and levator palatini muscles patient w/ unilateral cleft lip and palate, eruption of canine on cleft side most likely impaired

Pharyngeal reconstruction for VPI Sphincter palatoplasty: posterior tonsilar pillar containing palatopharyngeus is elevated, sutured, inset into posterior pharyngeal wall; functions to depress soft palate Pharyngeal flap: flap from posterior pharyngeal wall is elevated and attached to palate, usually for central palate defect Submucous cleft bifid uvula notching or absence of posterior nasal spine levator is more longitudinal mucosa between muscles is thinned and called zona pellucida (abnormal levator veli palatini)

complete unilateral cleft lip: ala is displaced lateral, inferior and posterior cleft lip and palate most likely requires Le Fort I maxillary advancement because of hypoplastic maxilla and class III malocclusion alveolar clefts are assoc w/ incomplete or complete cleft of primary palate success of secondary bone grafting of alveolar cleft depends on age of pt at time of grafting, ideally during time of mixed dentition gingival elevation for bone grafting of alveolar cleft: within gingival sulcus in pt w/ decidual dentition, above attached gingival in pt w/ adult dentition Alveolar grafting: use cancellous bone, eg. iliac bone, results in rapid revascularization cortical bone grafts have slow ingrowth of vessels and replacement of graft by host tissue over time Abbe flap: designed specifically to create functional philtrum in pts w/ tight upper lip following cleft repair pedicled on submucosal labial artery of lower lip, delayed division reconstructed philtrum should be < 10mm wide, < 15mm long uneven upper lip after rotation advancement should undergo re-rotation lip repair cleft nasal deformity: dome depressed, lateral crura displaced caudal, medial-lateral crura angle obtuse Lip defects: < 1/3 closed primarily w/ V or W-lip technique > 1/3 repaired w/ Abbe, Bernard, Estlander or Karapandzic flap

AESTHETIC AND BREAST Fitzpatrick skin types I white always burns, never tans II white usually burns, tans less than average III white sometimes burns mildly, tans about average IV white rarely burns, tans more than average V brown rarely burns, tans profusely VI black never burns, deep pigmentation Fitzpatrick skin classification according to skin pigmentation changes after exposure to uv light; types I, II, III have lowest risk of hyperpigmentation after chemical peeling best candidates for skin resurfacing are skin types I through III Most common benign lesion in Fitzpatrick type VI = dermatosis papulosa nigra (variant of seborrheic keratosis) Treatment for melasma in dark skinned (Fitzpatrick IV or V) is 1% tretinoin Lasers Q-switched Nd:YAG laser for removing tattoos o Q-switched Nd:YAG and alexandrite lasers are best used for removing blue-green tattoo pigments longer wavelength (1064 nm) for black/blue ink, shorter wavelength (532 nm) for bright colors Q-switched ruby and alexandrite lasers work, but penetrate deeper Q-switched ruby laser has wavelength 694nm, best absorbed by melanin and carbon in tattoo ink absorbing chromophore for tunable-dye laser functioning at wavelength 585 nm is oxyhemoglobin absorbing chromophore for CO2 laser is water Er:YAG laser vs carbon dioxide laser o Er:YAG has affinity for water 10X greater than carbon dioxide laser o shorter pulse duration o photochemical rather than photothermal o amt of collagen contraction is less o greater transudative wounds

carbon dioxide produces greater thermal affect on surrounding tissue, greater remodelling, greater cosmetic improvement o depth of treatment determined by energy per pulse (mjoules/pulse) laser abrasion effective for fine periocular rhytids Most common infectious complication after laser rx is herpes reactivation (2-7%); prophylaxis w/ acyclovir in all pts Non-surgical skin rejuvenation after face lift, surgeon should wait at least 3 months before phenol peel dermis after chemical peel has decreased non-lamellar collagen TCA peels, TCA is neutralized in dermis chemical peeling should be delayed 1-2 years safter stopping isotretinoin, or risk hypertrophic scarring Glycolic Acid (30-70%) alpha hydroxy acid, shorter recovery, limited to stratum corneum resulting in superficial desquamation, mild epidermal peeling, more subtle result, may need several treatments Best product for rx of fine to moderate facial rhytids: trichloroacetic acid (TCA) 15-35%, but need longer recovery; good for Fitzpatrick II Complications of TCA peel o Infection o Scarring o Hyperpigmentation (most common) transient, results from inflammatory changes caused by trauma to melanocytes Phenol chemical peeling complications o Arrhythmias: more common if h/o EtOH or liver dz o Hypopigmentation o Hyperpigmentation o Prominence of skin pores o Telangectasias o Erythema o Milia Jessners solution: evens depth of chemical peels and improves exfoliation; contains ethanol, lactic acid, resorcinol, salicylic acid Depth of phenol peel is decreased by using liquid soap dermabrasion is most appropriate for traumatic tattoos and perioral rhytids croton oil: skin irritant, increases speed and depth of epidermal destruction mechanism of retinoids is decreased activation of metalloproteases through inhibition of AP1 transcription; binds DNA receptor Tretinoin o most common complications of topical tretinoin therapy is erythema, scaling and xerosis o tretinoin thins stratum corneum, thickens epidermis, increases collagen synthesis o long term application of tretinoin results in formation of new type III collagen, Isotretinoin (Accutane) is contraindicated prior to dermabrasion (can lead to hypertrophic scarring, delayed healing; wait 1 yr) o Antikeratinization, thins stratum corneum, inhibits wound healing, impairs epithelialization by suppressing skin appendageal activity o Topical retinoids (Retin-A) do not have this effect Hydroquinone: tyrosinase inhibitor, used to prevent hyperpigmentation

Botox Botox takes 3-7 days for paralysis and lasts 4-6 months Botox injection into corrugator supercilii to treat glabellar frown lines can result in ptosis from diffusion of injection into levator muscles blepharoptosis after botox in glabellar region caused by migration of toxin into levator muscle, if severe alpha-adrenergic agonist eye drops (antalzoline, naphazoline) contract Muellers muscle

Recommended starting dose for glabellar wrinkles o 20 U at 5 injection sites o Muscles affected: corugator supercilii, procerus, depressor supercilii o Most common complication: upper eyelid ptosis Injection of botox into corrugator can diffuse to surrounding levator

Ptosis Levator function Good (>10mm)

Ptosis < 2mm

Good (> 10mm) Moderate (4-10mm) Poor (<4mm)

>3mm > 3mm > 3mm

Treatment Fasanella-Servat: shortens lower components of eyelid (partial excision tarsus, conjunctiva, Mullers muscle), used for mild ptosis if corrected by 2.5% phenylephrine (neo-synephrine) Reposition levator aponeurosis Levator resection Eyebrow (frontalis) suspension

Eyes

mild ptosis w/ normal levator function (> 10mm excursion) can be corrected w/ levator advancement surgical treatment of ptosis governed by degree of levator function: o 0-5mm (poor function, requires frontal suspension) o 6-10mm (moderate, levator resection necessary) o 10mm+ (good, aponeurotic surgery) Most common form acquired ptosis is degeneration of levator aponeurosis Neurogenic ptosis: loss of oculomotor nerve, loss of sympathetic innervation (Horners syndrome) myogenic ptosis: problems w/ levator muscle or tendon eg myasthenia gravis, aponeurotic degeneration mechanical ptosis: caused by weight of upper eyelid masses or traction by scars Levator advancement can correct moderate ptosis due to degeneration of levator aponeurosis Fasanella-Servat procedure (Mullerectomy): for mild ptosis, transconjunctival resection of portion of tarsus, conjunctiva, Mullers muscle and levator tendon more prominent eyelid crease can be produced with fixation of the levator aponeurosis to overlying dermis dehiscence of levator aponeurosis is most common cause of ptosis in elderly Treatment for congenital ptosis (absence of eyelid crease and 3mm levator function) is frontalis sling

Extraocular muscles Muscle Primary action Superior oblique Intorsion Superior rectus Elevation Medial rectus Adduction Lateral rectus Abduction Inferior rectus Depression Inferior oblique Extorsion

Secondary action Depression, abduction Adduction, intorsion None None Adduction, extorsion Elevation, abduction

Layers of eyelid: o Skin o Orbicularis o retro-orbicularis fat (ROOF) o orbital septum o orbital fat o levator tendon o Mullers muscle

o conjunctiva upper eyelid fat pads are anterior to levator aponeurosis lower eyelid fat pads are anterior to the inferior retractors Tenons fascia: covers globe Whitnalls ligament: o analogous to Lockwood superiorly o attaches medially to trochlea o attaches laterally to lacrimal gland and frontal bone o primary function is to limit excursion of levator palpebrae Lockwoods suspensory ligament: o fasica between inf oblique and inf rectus muscles o supports globe and contributes to lower lid retractors Asian eyelid: o Shallow orbits o Prominent globes o Epicanthal folds o Preaponeurotic fat lies in more caudal position secondary to orbital septum fusing with levator aponeurosis caudal to superior tarsal border o Levator muscle inserts into orbicularis closer to inferior tarsal border, causing lid crease to be much closer to inferior tarsal border o Asian eyelid has inferiorly prolapsed prelevator fat o Lack of insertions from levator aponeurosis into dermis During transconjunctival blepharoplasty, capsulopalpebral fascia is incised Blepharoptosis secondary to acquired dehiscence of levator aponeurosis o High eyelid crease o Excellent levator function o Margin to reflex distance of 0 mm o Rx: reanastomosis of dehisced levator aponeurosis Chemosis : edema, ecchymosis, swelling of chonjunctiva, normal acuity; rx w/ dexamethasone ophthalmic ointment

Ectropion = eversion of eyelid margin, best treated w/ wedge excision procedure o Caused by scarring between orbital septum and capsulopalpebral fascia o Treatment for post-op ectropion assoc w/ shortening of anterior lamella and horizontal laxity of lower lid (scleral show, lid retraction) = lateral tarsal strip w/ full thickness skin graft o Smith lazy T excision: full section of lower eyelid along w/ horizontal conjunctival elliptical excision performed inferior to medial puncta o Kuhnt-Szymanowski procedure: full-thickness wedge excised in region of lateral canthus cicatricial ectropion is best treated w/ full thickness skin grafting Ectropion w/ Bells palsy is from paralysis of orbicularis oculi Ectropion after repair of orbital floor fx: o Transconjunctival 0% o Subciliary 25% Entropion: inward turning of eyelid and eyelashes o Correction involves subciliary skin excision, suturing superior edge of wound to inferior tarsus and release of conjunctival adhesions o Causes: redundancy of skin and orbicularis (young), laxity of canthal tendons or tarsal plate (atrophic changes in adults) Epiblepharon: congenital condition of horizontal skin excess on eyelid caused by abnormal insertion of muscle fibers o epiphora, corneal abrasions from eyelashes rubbing on cornea

o o o o

most common cause is excess pretarsal skin and orbicularis at lower eyelid margin usually lower eyelids more common in Asians treatment is resection of redundant pretarsal skin and orbicularis muscle

blepharochalasis syndrome: recurrent edema of eyelids w/o assoc pain or erythema; eyelid redundancy and atrophy lead to laxity of lateral canthal tendon blepharophimosis syndrome: form of congenital ptosis o type 1: large epicanthal folds, epicanthus inversus, horizontally shortened eyelids, severe ptosis o type 2: telecanthus, absence of epicanthal folds, severe bilateral ptosis, absence of levator function, skin shortage of all 4 limbs o type 3: absence of epicanthal folds, telecanthus, antimongoloid slant of palpebral fissures, severe ptosis, mild orbital hypertelorism, skin deficiencies Retrobulbar hematoma o Steady severe lancinating pain o Firmness and tenderness of globe, discharge from eye o IV acetazolamide, corticosteroid o Operative exploration o Ophtho consult

Epiphora = caused by excess tear production, or obstructed lacrimal drainage system; excess tearing, best corrected by dacryocystorhinostomy Jones I dye testing: involves instillation of 2% fluorescein dye into conjunctival fornices, recovery of dye = lacrimal duct uninhibited (positive), if negative Jones I, do: Jones II: nasolacrimal system irrigated w/ 1ml saline via irrigation cannula o Dye at inf turbinate = partial obstruction of lower canalicular system o Dye within tear sac = obstruction of nasolacrimal duct, canaliculus and lacrimal pump unaffected o No dye stained fluid in nose = negative test, obstruction at cannalicular level o If Jones II is positive, dilate puncta, if patency not restored, do dacrocystorhinostomy

dacryocystorhinostomy involves burring hole through lacrimal fossa into nasal cavity, which is connected to the lacrimal sac Common canaliculus enters lacrimal sac posterior to medial canthal tendon

Congenital tearing = nasolacrimal duct problem o Rule out w/ dye testing o Treat w/ massage and ABx drops until 12-13 mo (resolves in 70% by then) o If > 13 mo, probe nasolacrimal duct, if unsuccessful, Silastic intubation, then dacrocystorhinostomy Blepharochlasis vs. dermatochlasis o Blepharoclasis: results from recurrent nonspecific inflammatory edema of eyelids, results in thinning, redness of skin, pseudoepicanthal folds, disinsertion of lateral canthal tendon o Dermatochlasis: baggy eyelids from loss of elasticity of aging, skin redundancy, upper > lower Treatment for scleral show, sad eyes with poor snap back test is lateral canthopexy excessive fullness of lateral orbit most commonly due to lacrimal gland shortening and scarring of posterior lamella and septum after ORIF of malar complex fracture can cause malpositioning of lower eyelid Most common complication following transcutaneous bleph: malpositioning of eyelids Correction of eyelid retraction in pts w/ Graves disease: levator resection w/ interpositional grafting

Superior oblique is most commonly injured in blepharoplasty 2ndary to superificial location, sx include pain, diplopia, tendency to close 1 eye, abnormal tilting of head, depression of chin Traumatic aponeurotic ptosis: levator aponeurosis detached from tarsal plate; good levator function, elevation of eyelid crease, ability to visualize shadow of iris w/ eyelid closure (positive Nesi sign) lid retraction after bleph can be caused by scarring betwn orbital septum and capsulopalpebral fascia Eyelid function in pts w/ unilateral idiopathic facial nerve paralysis is ectropion resulting from dysfunction of orbicularis treatment for full thickness lower eyelid defect is Hughes tarsoconjunctival flap

Ears

Innervation of ear o Greater auricular nerve (C2-C3): lobule, helix, antihelix, most of cranial surface o Auriculotemporal (V3): tragus, root of helix o Greater occipital (C2-C3): posterior scalp o Lesser occipital (C2): upper third of cranial surface of ear, anterior superior external auditory canal o Vagus (nerve of Arnold): concha, external auditory canal

Auricle arises from 6 hillocks derived from 1st and 2nd pharyngeal arches o Anterior 3 hillocks from 1st (mandibular) pharyngeal arch: tragus, helical root, superior helix; drain into parotid LN o 4th 6th posterior hillocks from 2nd (hyoid) pharyngeal arch: antihelix, antitragus, inferior helix, lobule; drain into cervical LN Microtia abnomal development of 1st and 2nd branchial arches during 1st trimester, associated with other abnormalities in o Goldenhar syndrome (orbital auricular vertebral syndrome): Cervical spine abnormalities, mandibular hypoplasia, preauricular pit and sinuses, epibulbar dermoids, hemifacial microsomia o Tessier No 7 cleft: macrostomia, preauricular sinuses o pts with microtia have abnormal external ear structures: ossicles, ext auditory canal, middle ear cavity, tympanic membrane o inner ear is normal helical root arises from concha cauliflower (wrestlers) ear: acute subperichondral hematoma; complete evacuation of hematoma w/ lateral incision and dissection followed by splint dressing

Prominent Ear Normal ear measurements: o Height 5.5-6 cm o Width 3-4.5 cm o Helical rim is 10% of vertical height (7mm) o Protrusion 10-12 mm at helical apex, 16-18 mm at midpoint, 20-22mm at lobule prominent ear due to obtuse concha-mastoid angle corrected w/ concha-mastoid sutures through mastoid periosteum prominent ear deformity is characterized by: o protrusion of the helical apex > 12mm o absence of posterior fold o conchal valgus o underfolding of antihelix o scaphoconchal angle > 90 deg o cephaloauricular angle > 25 o (M), 21 o (F) Most common cause: loss of antihelical fold, conchal hypertrophy

otoplasty for prominent ears, antihelical fold is created by placing mattress sutures in cartilage of posterior ear placement of sutures from conchal bowl to mastoid fascia and rasping of anterior surface of antihelical cartilage is for correcting prominent ears prominent ear deformity treatment: conchoscaphoid (Mustarde) or conchomastoid suturing Otoplasty techniques o Furnas: sutures placed from concha to mastoid to diminish size of (>2.5 cm) o Mustarde: recreates antihelical fold w/ mattress sutures on posterior aspect of antihelical fold o Stenstrom cartilage abrasion: anterior antihelical surface scored, scratched or abraded, causes cartilage to bend away from abraded surface to create posterior roll o Webster: fixation of helical tail to concha o Luckett: crescent-shaped portion of skin and cartilage excised from length of antihelix, edges sutured to create antihelical fold o Graham and Gault: scoring and suturing posterior cartilage most common complication after otoplasty is residual or recurrent deformity

Other Ear Deformiites Stahls ear: third crus, flattening of antihelix, malformation of scaphoid fossa (broad and flat), absent superior crus, pointed ear (Spock) o Rx is advancement or resection of third crus of antihelix

constricted ear: hooding of helix and scapha telephone ear deformity: excessive reduction of the concha or inadequate correction of prominent upper and lower poles of the ear during otoplasty Cryptotia: superior portion of auricle is adherent to temporal skin; rx is release of adherent part and skin graft constricted ear deformity: helical rim is constricted, superior portion folds over scapha; rx is partial detachment of helix from scapha and resuturing helix at more appropriate angle

Ear Reconstruction defect of helical border reconstructed with helical rim advancement flap Reconstruction of lateral helical rim defects: Anita Buch flap: local flap using tissue from helical rim based on postauricular skin to reconstruct helical margin

Ear reconstruction in patient with inadequate skin coverage osteointegrated screws and prothesis Full thickness loss of rim, antihelical fold, concha can be reconstructed w/ a postauricular transposition skin flap For ear replantation, large ear vessels are on posterior aspect of ear; connect to anterior auricular branch of superficial temporal artery and branch of occipital artery Principal indications for osseointegrated implants for ear recon: major cancer extirpation, poor local tissue, absence of lower half of ear, salvage following unsuccessful surgery, poor operative risk o Primary disadvantage of banking amputated ear cartilage subcutaneously is warping

Estrogen on developing ears o Molding therapy of ear deformities in 1st 6 wks of life o Maternal estrogen o Increases hyaluronic acid making ear cartilage more pliable

Nose Sensory innervation of nose: o Septum: nasopalatine nerve inferiorly, ant ethmoid superiorly o Nasal lobule: ant ethmoid o Superolateral external nose: infratrochlear o Inferolateral: infraorbital o Lateral wall of nasal cavity: sphenopalatine ganglion and posterior nasal nerve, internal branch of nasocililary nerve Nasal innervation o Anterior ethmoidal nerve external branch:skin of nasal tip and alae internal branch: septum and internal nasal walls o infraorbital nerve: cheek, lip, lower eyelid, upper gingival o nasoplatine nerve: septum, hard palate o lesser palatine nerve: uvula, tonsil, soft palate o infratrochlear nerve: skin of radix nasal radix supplied by supratrochlear and infratrochlear nerves Blood supply to nose o Tip (facial art): lateral nasal artery from angular art, columella branch of superior labial o Septum: nasopalatine, ant. Ethmoid, post ethmoid, posterior septal art, perforating branch of superior labial art Muscles that affect nose: o Nasalis and levator labii superioris (alar fibers) dilate nasal aperture

o Nasalis (transverse fibers) constrict nostrils o Depressor septi nasi depresses nasal tip o Innervated by buccal branch o Facial paralysis can contribute to nasal airway obstruction (nasalis) Middle meatus marks path of primary inspiratory nasal current Erythema after rhinoplasty, treat w/ antibiotics secondary rhinplasty should be delayed at least 1 yr Best way to reconstruct ala is composite graft from ear (1.5-2 cm max) Worst result of secondary healing in nose is the tip, other areas (canthal bowl, columella, glabella, sidewalls) have 85-100% acceptable results o Best result is medial canthal area Rhinoplasty methods for treating dorsal hump: o Augmentation of saddle-nose deformity o Augmentation of radix with dorsal implant o Rasping of hump o Resection of hump, followed by osteotomy and infracture Resecting upper lateral cartilages and septum as unit Resection of alar domes decreases nasal tip projection bilateral retracted alar rims can be corrected with composite septal graft to the alar vestibule alar wedge resection treats flared nostrils Weir excisions: resections of alar base to reduce wide or flaring nostrils procedures that correct tip projection can cause broad based nose corrected by Weir-type alar resection or nasal sill resection o increase tip projection: cartilage graft to tip, suturing medial crura, placing strut graft between medial crura, resect caudal margin of septum and cephalic alar rim o decreases tip projection: resecting lateral and medial crura and nasal spine, complete transfixion incision dorsal supratip convex deformity caused by underresection of dorsal aspect of septum supratip deformities: caused by inadequate resection of dorsal spine or excessive resection of nasal dorsum Pollybeak deformity = supratip deformity o Nasal tip lacks projection relative to dorsum o Lack of tip projection caused by overresection of lower lateral cartilages o Overprojection of caudal nasal dorsum and inadequate preservation tip projection o Caused by either overresection of dorsum (90%) (supratip compressible) or underresection of dorsal septum (supratip not compressible) o Corrected by increasing nasal tip projection w/ cartlage grafts

Rhinoplasty tip projection Tip grafting Suture medial crura Strut graft between medial crura Resection of caudal margin of septum and cephalic alar trim rotates tip, increases projection subtly transdomal sutures: horizontal mattress sutures that narrow domes, narrows convexity of lateral crura interdomal sutures affect columellar projection and tip projection control tip symmetry: interdomal and transdomal sutures Decreasing tip projection Resection of lateral and medial crura Resection of nasal spine Complete transfixion incision (by weakening nasal support)

shield graft and transdomal sutures increase tip projection Nasal tip drooping, elongation of tip complex w/ aging is caused by: o *Loss of intrinsic lower lateral cartilage support o Weakening or loss of suspensory ligament support o Loss of medial crural support o Thickening and possible ossification of cartilages o Thickening of overlying skin o Maxillary alveolar hypoplasia w/ divergence of medial crural feet and columellar shortening most likely complication after correction of poorly projecting nasal tip is graft visibility pinched nasal tip: most appropriate surgical technique is insertion of alar grafts septal extension graft: large cartilage graft anchored to septum to control nasal tip projection dorsal nasal flap used primarily to cover defects of nasal tip Cephalad resection of lateral alar crus moves tip cephalad, decreases fullness, increases definition of tip defining points

Nasal Airway Nasal obstruction by forced inspiration likely caused by internal nasal valve angle < 10 degrees Nasal valve = septum, nasal floor, and caudal edge of upper lateral cartilage o normal is 10-15 degrees formed between caudal end of upper lateral cartilage and septum o < 10 deg causes airway obstruction Rhinoplasty in pts w/ breathing difficulties should address: o Internal nasal valve o Nasal septum o Nasal vestibule o turbinates Cottle test: o lateral traction on paranasal skin of left cheek, distracts upper lateral cartilage away from septum and opens angle of internal nasal valve o improvement in airflow is considered positive confirming obstruction at internal nasal valve o Negative Cottle test localizes nasal obstruction to external nasal valve o to correct external nasal valve collapse, lateral crural strut graft inserted btwn vestibular lining and lateral crus of lower lateral cartilage Spreader graft o placed along dorsal septum, between dorsum of septum and upper lateral cartilage o extends posteriorly to improve internal nasal valve collapse o Spreader grafts originally described for primary rhino in pts predisposed to middle vault collapse o can also be used to buttress high dorsally deviated septum o also recreates dorsonasal line most common cause of nasal obstruction is enlarged inferior turbinates, best treated by anteroinferior turbinate resection excessive resection of upper lateral cartilage results in collapse of middle vault; correction is with spreader grafts Infracture of nasal bones most common adverse effect is narrowing internal nasal valve (angle betwn upper lateral cartilage and septum) batten graft is placed across midportion of quadrangular cartilage of septum, doesnt correct external or internal nasal collapse Hanging columella: o Results from prominence of caudal margin of septum or marked convexity of caudal margin of medial crura of lower lateral cartilage o Rx: resection of caudal margin septum, caudal resection of medial crura of lower lateral cartilage o Treatment of hanging columella = resect caudal septum

Causes of saddle nose deformity: o Excessive resection of nasal dorsum o Excessive resection of septum o Fracture of perpendicular plate of ethmoid o Comminution of nasal bones during infracture that results in displacement of piriform aperture o Treatment for saddle nose deformity: onlay grafting of cartilage or bone Nasal fractures Upper vault: nasal bones, ethmoid, vomer, cephalic septal border middle vault: upper lateral cartilage, septum, maxilla lower vault: nose, alar cartilages, inf septum

Acute treatment of nasal fractures: Close realignment of fracture w/ forceps Drainage of septal hematomas Intranasal packing Dorsal nasal splint Most significant sign of septal fracture is tearing of mucosa Characteristics of Asian nose: Alar flare Bulbous nasal tip Thick subcutaneous tissue Wide flat dorsum Poorly projecting nasal tip Face Anatomy: supraorbital nerve (branch of V1), deep and superficial branches o deep: supplies central frontoparietal scalp o superficial: sensation to central forehead and hairline

Temporal scalp: V2, V3 Temporal or frontal branch of facial nerve courses deep to superficial temporal fascia above zygomatic arch muscles of facial animation are innervated deep to muscle, except: buccinator, mentalis, levator anguli oris which are innervated from superficial zygomatic ligaments suspend soft tissue in malar region over zygomatic eminence o loss of support from zygomatic ligaments occurs adjacent to the nasolabial fold making it prominent zygomatic orbital or orbital retaining ligaments: o located over zygomatic frontal suture o 5mm fibrous band attaches ZF suture to dermis o release allows superior-lateral movement of forehead Fence of the cheek: attachments that are the retaining ligaments, release allows free movement of skin and soft tissue of face o Anterior-inf border of mandible in parasymphyseal region anterior to jowl o Anterior-inf border of zygomatic arch posterior body of zygoma (McGregor patch) o Buccal maxillary ligaments from zygomatic maxillary suture to dermis pseudoherniation of buccal fat pad results from weakening of buccopharyngeal membrane Buccal branch: innervates levator labii oris, lies superficial to parotid fascia and deep to SMAS

Galea-frontalis, temporoparietal fasica (AKA superficial temporal fascia), SMAS, orbicularis oculi, platysma and superficial cervical fascia all form single continuous layer Layer deep to SMAS layer: cranial periosteum, deep temporal fascia, parotidomasseteric fasica, deep cervical fascia temporalis lies deep to deep temporal fascia o blood supply is deep temporal artery exposing Z arch through coronal incision, incise superficial layer of deep temporal fascia at level of lateral orbital rim to protect frontal branch of facial nerve

Facelift Buccal branch of facial nerve is most commonly injured during rhytidectomy Most common nerve injured is greater auricular o Found crossing SCM 6.5 cm below caudal edge of ext auditory canal o Also described as 6 cm below tragus and 9 cm below EAC Periop steroids dont affect edema or ecchymosis after rhytidectomy most common complication of rhytidectomy is hematoma o hematoma after rhytidectomy: 7-8% in men, 3.4% in women o quoted as 3-5% overall most common complication after 2ndary rhytidectomy is distortion of the hairline dissection in sub-SMAS plane beyond zygomaticus major muscle will denervate the muscle Injury to frontal and zygomatic branches of facial nerve: corneal exposure, loss of elevation of ipsilateral eyebrow; rx if late finding is gold wts and ipsilateral brow lift Acute facial nerve injury: tag damaged nerve ends and reapproximate within 72 hrs; primary nerve repair most likely to result in satisfactory return Secondary rhytidectomy more likely to result in distortion of hair line Blood supply to preauricular skin is transverse facial artery Genioplasty most common complication of retrogenioplasty is permanent or temporary numbness of chin most common cause of loss of chin projection after silicone implant is bone erosion under implant bony chin deformity characterized by sagital deficiency and vertical mandibular excess is best treated w/ jumping genioplasty assess dental occlusion in any pt considering chin implant Chin implants enhance sagital projection to pogonion Microgenia w/ AP and vertical deficiency of chin rx w/ osseous genioplasty Alloplastic chin aug is best for minimal sagital (horizontal) deficiency of lower face, shallow labiomental fold, symmetric and normal height of lower face; not appropriate for chin asymmetry Increased incisal show after genioplasty is due to inadequate repair of mentalis muscle Brow transverse rhytids along root of nose are improved w/ resection of procerus (contraction pulls forehead downward and root of nasal tip upward) corrugator supercili originates along periosteum and medial orbital rim and inserts into dermis of medial brow, causes vertical glabellar wrinkling frontalis inserts on skin of forehead causing transverse forehead rhytids forehead flap is based on supratrochlear artery female brow should peak from lateral limbus to lateral canthus male brow is lower, at orbital rim, usually horizontal w/o significant peaking Endoscopic brow lift assoc w/ lower incidence of scalp sensibility changes Transverse creases at radix caused by procerus Longitudinal lines at glabella caused by corrugator Primary movers of brow: o Lateral depressor orbicularis oculi o Medial depressor depressor supercilii

o Elevator frontalis Other pain after onset of Bells palsy is treated w/ prednisone most common late complication of alloplastic malar augmentation is malposition Appropriate position of malar implant is in submalar area over upper masseter muscle Rx for pt with heavy appearing eyes and glabellar rhytids: open browlifting through hairline incision, including resection of corrugator and procerus muscles resorption of malar soft tissues after advancement of malar fat pads is caused by disruption of angular artery branches a. advancement < 2 cm, submalar dissection is ok b. > 2cm advancement, dissect superficial to fat pad Breast Breasts are 50% fat Breast anomalies: o amazia: absence of glandular tissue only o athelia: absence of nipple alone o amastia: congenital absence of breast and NAC

Tuberous breast deformity: o herniation of breast tissue into nipple areola complex o cylindrical projection accompanied by large areola o deficiency of lower pole of breast o hypoplasia o deficient skin envelope o Rx: periareolar or Wise-pattern mastopexy (depending on degree of ptosis), radial-releasing incisions to exand base, augmentation Poland syndrome: o unilateral aplasia or hypoplasia of pectoralis major muscle o adjacent musculoskeletal components: aplasia or hypoplasia of breast or nipple, partial agenesis of ribs and sternum, anomalies of shoulder girdle, axillary banding o ipsilateral hand anomalies, brachysyndactyly of ipsilateral upper extremity ectopic polymastia (outside milk lines), most common affected site is dorsal thigh, scalp, ear, back, shoulder, epigastrium accessory polymastia (within milk line), 90% is in chest region accessory mammary structures found along embryonic milk lines, most supernumerary breasts most commonly in axilla and groin Sensation to nipple areola complex: lateral cutaneous nerve from T3-T5, but T4 is the primary nerve Breast innervation is T2-T6 Sensitivity o Most sensitive part of breast to light pressure is superior quadrants o Nipple least sensitive to light pressure o vibration most sensitive in areola o sensitivity decreases w/ age and size of breasts Nipple-areola characteristics in men: o 20cm from sternal notch, 18 cm from midclavicular line o Nipple-nipple distance 21 cm o Oval, 2.7-2.8 cm diameter

Augmentation textured saline implants are known to exhibit visible wrinkling shell of saline breast implant is polydimethylsiloxane (silicone rubber) altered nipple sensation following augmentation is 15% regardless of incision due to 4th lateral intercostals nerve injury

most critical factor in determining need for breast contouring after removal of breast implants: degree of pre-op ptosis o (Grade II or III): thickness of breast parenchyma determines viability of performing breast contouring Factors affecting screening mammo in pts w/ breast implants: o Baker III capsular contracture o Implant location o Native breast volume Transaxillary breast aug assoc w/ implant malposition, can be decreased w/ endoscopic approach 10 year risk of reoperation after saline breast aug is 25% Blunt dissection lateral to lateral edge of pec during breast aug preserves sensation of NAC fibrinogen implicated in implant capsule formation Breast pocket irrigation during saline aug: bacitracin, cefazolin, gentamicin reduces capsular contracture Subglandular placement increases risk of capsular contracture w/ smooth, silicone implants

Mastopexy, Reduction Breast ptosis caused by elongation and laxity of Coopers ligaments Breast ptosis: 1st degree: at level of IMF 2nd degree: below IMF 3rd degree: nipple at lowest point on breast pseudoptosis: breast mass desends behind NAC which is above IMFwidening of areola is the most common complication following periareolar mastopexy vertical (Lejour) mammaplasty: central vertical glandular excision Calcifications seen in 25% after breast reduction Indications for delayed mastopexy after implant removal o Severe ptosis requiring nipple elevation > 4 cm o Breast mound smaller than 4 cm o Significant smoking hx Type of mastopexy depends on ptosis and nipple elevation needed o Grade 1 ptosis, < 2 cm nipple elevation periareolar mastopexy o Areola diameter > 50mm, > 2 cm nipple elevation vertical mastopexy o Grade II ptosis, repositioning of nipple 2-4 cm Wise pattern mastopexy Other Breast Innervation of pectoralis o Major: lateral pectoral nerve (C5-6) suppies medial portion, medial pectoral nerve (C8-T1) supplies lower lateral sternal portion o Minor: medial pectoral nerve Breast reconstruction with delayed autologous tissue flap yields best appearance postmastectomy and radiation extended latissimus dorsi myocutaneous flap advantage is decr need for implant TRAM in smokers have increased risk of: o abdominal flap necrosis

o mastectomy skin flap necrosis o hernia risk of post-op complications w/ TRAM is least likely to be associated w/ previous radiation rx o complications are associated w/ age, body habitus, h/o DM, h/o smoking BRCA-1 o 60% incr risk of breast cancer o Incr risk ovarian, prostate, colon ca o Locus chromosome 17 BRCA-2 o Incr risk breast cancer (60%), not ovarian Gynecomastia: genital exam should be done first (testicular tumors, nonpalp or undescended testes), if abnormal, initiate genetic or endocrine exam workup

Other Cosmetic most common complication of belt lipectomy = seroma (33%) During medial thigh lift, stay superficial over femoral triangle to avoid injuring lymphatics nerves at risk during abdominoplasty: iliohypogastric, ilioinguinal, intercostals Liposuction primary indication for SAL of neck is presence of excess supraplatysmal fat, can be determined by pinch test > 2 cm; good skin tone SAL of calves and ankles: better satisfaction if > 1.5 cm pinch test upper arm skin laxity caused by loosening of clavipectoral fascia most common complication after UAL is seroma Liposuction techniques Technique Infiltrate Blood loss % of total aspirate Dry None 20-45% Wet 300ml per region 4-30% Superwet 1ml : 1ml aspirate 1% Tumescent 2-3ml :1ml aspirate 1% 10-30% of lidocaine injected in tumescent technique is suctioned out o lidocaine toxicity CNS 5-9 mcg/ml plasma concentrations o peak lidocaine plasma levels occur 12 hrs after infiltration

Max safe dose of lido for tumescent liposuction is 35 mg/kg (but up to 55 mg/kg reported) Hydration for suction lipectomy = infiltrate + IVF = aspirate volume x 2 Rate of lidocaine absorption during SAL prevents toxicity Local anesthetics: o Esters: cocaine, procaine, benzocaine, tetracaine, chloroprocaine (allergies occur w/ esterlinked) o Amides : lidocaine (4.5/7), mepivacaine, bupivacaine (175/225 mg), etidocaine, prilocaine o cocaine is the only LA with sympathomimetic effects o Duration determined by protein binding (higher binding, longer action) o Potency determined by lipid solubility (higher solubility, higher potency) o Onset of action determined by pKa (lower has more rapid onset) Increasing levels of plasma lidocaine affect: CNS, heart rate and muscle tone (seizures); but not blood pressure

Hair male pattern alopecia: dominant, sex linked gene, increased 5 alpha-reductase in follicles hair follicles are in the subcutaneous layer of scalp Anatomy of hair follicle: dermal papillae bulb consisting of dermal and epidermal coat Micografts contain hair follicles and dermal elements (neurovascular bundle, sebaceous gland, sweat glands, piloerectile muscles) surrounded by collagen following punch graft transplantation:

growth for 1 month, followed by hair loss o then new normal growth after 3 months o wait 4 months between hair grafts 6 months before permanent hair growth scalp reduction is the most appropriate for male pattern alopecia, do before establishing anterior hairline termporoparieto-occipital (Juri) flap : transplanted hair grows posteriorly expanded bilateral advancement transposition flaps: hair grows more anteriorly, less noticeable scar primary advantage of using expanded bilateral advancement transposition (BAT) flaps vs. Juri flaps is direction of hair growth anagen: active hair growth (90% of scalp in this phase, lasts 3 yrs) catagen: follicular bulb destroyed, base of hair keratinized, lasts 2-3 wks telogen: resting phase, follicle inactive 3-4 months (10% of follicles) selective thermolysis removes hair that have melanin (anagen hairs), prolongs telogen autologous fat injection only 50% of original fat remains after 6 months most common complication of full abdominoplasty and suction lipectomy is seroma formation Abdominoplasty + SAL has highest complications in central infra-umbilical areas Smoking and abdominoplasty 50% complication rate o pts should quit 8 wks before, 4 wks after surgery adverse effects with transverse excision lipectomy: flattening of gluteal fold and asymmetry of buttocks and hypertrophic scarring most common long term unfavorable result after brachioplasty is widening of scar Exposed porous polyethylene can be managed w/ dressing changes b/c it allows for tissue ingrowth Nerves at risk for injury o Genitofemoral: L1-2, inserts into abdomen above ing ligament, divides into genital, femoral branches supplying scrotum, mons, labia and sensation over femoral triangle o Iliohypogastric: L1, lateral and anterior branches to supply lateral buttocks, abdomen above pubis respectively o Ilioinguinal: L1, through inguinal ring to supply superomedial portion thigh, scrotum or mons o Obturator nerve: L2-4, skin of medial and lower thigh o Lateral femoral cutaneous: L2-3, through inguinal ligmament 1 cm medial to ASIS, superficial to sartorius, divides into anterior and posterior branches; anterior branch becomes superficial 10cm below ASIS

Skin Lesions eccrine poroma: o benign tumor of sweat duct o painful papule on sole or sides of feet, appear in middle age, firm, < 2 cm diameter, treated by surgical excision pilomatricoma: calcifying epithelioma of Malherbe o benign pediatric tumor of head and upper ext o large, painless dermal or subcutaneous mass o contains hair matrix and collagen trichoepithelioma: small, flesh-colored papule usually on face, benign tumor from hair structures nevus flammeus neonatorum: fading macular patch in 50% of neonates (salmon patch) nevus of ota: brownish blue lesion in distribution of 1st and 2nd branches of trigeminal nerve nevus araneus: central elevated blood vessel w/ fine, radiating vessels, no malignant potential keratoacanthoma: well-circumscribed lesion, firm, rounded borders, umbilicated scaly center o keratoacanthoma undergo 3 phases: rapid proliferation, maturation, involution o typically in men > 50 yrs o grow rapidly then regress spontaneously

resemble SCC

actinic keratosis: premalignant keratotic papule, 25% chance of progression to SCC seborrheic keratosis: superficial plaque cutis laxa: nonfunctioning elastase inhibitor or premature degeneration of elastin fibers; pts have coarsely textured, drooping skin; its not associated w/ wound healing problems Ehlers Danlos: abnormal collagen cross linking, hyperextensible joints, poor wound healing

INTEGUMENT Wound healing Ratio of type I to type III collagen: o Normal: 4:1 o Hypertrophic and immature scars: 2:1 Collagen o Type I: 90% of body tissue, bone, tendon, skin; most abundant collagen in healed scar o II: hyaline cartilage, eye o III: skin, arteries, uterus, intestinal wall, fetal wounds o IV, V: basement membrane TGF beta stimulates fibroblasts to produce collagen Molecular cross-linking of collagen provides maximal tensile strength Collagen synthesis o Hydroxylation of prolene and lysine on procollagen occurs intracellularly o Procollagen secreted from cells, amino and carboxy terminal cleaved to form collagen molecule o Collagen molecules crosslink to form collagen fibril o Fibrils crosslink to form collagen fibers Colchicines prevents secretion of helical collagen (tropocollagen) from cell by inhibiting cleavage of pro segment Deficiency of copper or penicillamine inhibits collagen cross-linking, preventing formation of collagen fibers from tropocollagen Recurrence rate for keloid is 55% Deep mechanical massage results in accumulation of dense longitudinal collagen bands, distortion and disruption of adipocytes Order of appearance of cells in wound healing o Hemostasis, inflammation: RBCs, platelets o Neutrophils (peak at 24 hrs) o Lymphocytes, macrophages o Fibroblasts, epithelial cells, endothelial cells Sequence of events: o Vasoconstriction o Vasodilation o PMN infiltration o Re-epithelialization o Collagen synthesis o Contraction Wound healing: o Decreased condroitin-4 sulfate, hyaluronic acid o Increased water o Increased type I collagen Changes in dermis w/ age: ground substance increases, collagen and fibroblasts decrease Deep mechanical massage increases accumulation of collagen bands

Eponyms Sturge-Weber syndrome: complex deformities characterized by vascular malformation of the face (capillary malformations), esp V1 and V2; and lesions in choroids plexus and meninges; glaucoma, calcifications of outer layers of cerebral cortex, focal motor seizures, hemiparesis, visual field defects, glaucoma, leptomeningeal venous malformations may cause mental retardation Rendu-Osler-Weber syndrome: hereditary hemorrhagic telangiectasia, autosomal dominant; lips, tongue, oral mucosa, GI tract; pulmonary and CNS affected (epistaxis, hemauria, hematemesis, melena) Von Hippel-Lindau disease: hemangiomas of retina, hemangioblastomas of cerebellum and viscera, seizures, mental retardation Maffuccis syndrome = venous malformations and dyschondroplasia (usually multiple enchondromas, frequently affecting the hand) Olliers disease (multiple enchondromatosis) is caused by abnormal endochondral ossification, benign cartilaginous tumors in the large and small tubular bones Klippel-Fiel syndrome: short neck, low posterior hailine, fusion of cervical vertebrae Klippel-Trenaunay: limb hemihypertrophy, most commonly leg, assoc port-wine stain, lymphatic and venous malformations Parkes-Weber syndrome: skeletal hypertrophy of 1 extremity associated w/ A-V fistulas ( like K-T but with AVM) Milroys disease: X linked, autosomal dominant, primary lymphedema diagnosed at birth Bazex syndrome: X linked, autosomal dominant, follicular atrophoderma, hypertrichosis, hypohidrosis, multiple BCC Muir-Torre syndrome: autosomal dominant, multiple skin malignancies, colon, kidney, bladder, ovary, pancreas, breast cancer ** In pt w/ multiple skin malignancies, including keratoacanthoma, get colonoscopy Werners syndrome: autosomal recessive, sclerodermic skin changes and accelerated atherosclerosis Proteus syndrome: partial gigantism of extremities, hemifacial hemihypertrophy, macrocephaly, macrodactyly, localized exostoses, subcutaneous lipomas, vascular malformations Progeria (Hutchinson-Guilford syndrome): recessive, skin laxity, loss of subcutaneous fat, atherosclerosis, poor wound healing Skin Grafts STSG: 1) Plasmatic imbibition (24-48 hrs) 2) Inosculation (vascular ingrowth) 3) Capillary ingrowth thin STSG undergoes lowest primary contraction and greatest secondary contraction return of sensation in STSG: pain, light touch, cold, warm, vibratory Treatment for dusky composite graft is hyperbaric oxygen (arterial insufficiency) Number of times a donor site can be harvested for STSG depends on thickness of skin cultured keratinocytes: takes 3 wks to prepare, grown in murine fibroblasts and fetal calf serum, lack dermal component, fragile, expensive can be stored for 14 days at 3-5 deg C, but for proper graft take, use w/in 7 days only 15% of original collagen remains after 5 mo Tissue Expansion Tissue expansion of random-patterned skin flaps: o Increases survival o Thickening of epidermis (stratum spinosum) by cellular hyperplasia and intercellular narrowing o total collagen content unchanged o Thinning of dermis, subcut tissue, flattening of rete ridges o Proliferation of vascular cells

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Decreased elasticity, tensile strength multilayer capsule

tissue expansion in lower extremities in children is assoc w/ onset of complications immediate tissue expansion causes realignment of collagen fibers and displacement of interstitial fluid from dermis and microfragmentation of elastic fibers in dermis

Cartilage Grafts primary disadvantage of autologous cartilage graft is warping use of a symmetric cartilage graft decreases warping Autologous cartilage has the least resorption and loss of volume of autologous grafts Prolonged survival time of homologous cartilage grafts before implantation is due to proteoglycan matrix autologous ear reconstruction preferred to synthetic because of risk of extrusion Growth of reconstructed ear in microtia is dependent on presence of perichondrium symmetrical grafts decrease cartilage warping when used as graft cartilage allografts have immunologic privilege b/c barrier protection of mucopolyamines Fat Grafts Most common complication of autologous fat grafting = undercorrection o Graft retention 40-78% Flaps interpolation flap: flap pivots, retains its pedicle as a central point of fixation while being rotated around and transferred to a distant site, travels over or under intervening tissue eg. Paramedian forehead flap advancement flap: moves directly forward over defect w/o any rotation (V-Y) o Burrows triangle is typically used w/ an advancement flap rotational flap: rotated around pivot point (gluteal fasciocutaneous flap) transposition flaps: rectangular pivot flaps raised adjacent to recipient defects (bilobed flap, Limberg, and Z-plasty) columellar defects can be covered w/ nasolabial flap (based on angular artery) surgical delay incisions increase blood flow (increased size and number of vessels) to a max at 4th day after incisions Muscle Flap classification Type I 1 major pedicle: TFL, gastroc, vastus lateralis, rectus femoris Type II Major and minor: Gracilis, trapezius Typ III 2 major: Rectus abdominis, gluteus maximus, serratus Type IV Multiple segmental: sartorius, external oblique, tib ant, extensor ditigorum longus Type V Major and multiple segmental: latissimus, pec major Serratus anterior: lateral thoracic artrery, serratus branch of thoracodorsal artery Reverse flow sural artery flap o Distal dissection stops 5 cm above lateral malleolus to preserve peroneal artery anastomoses o Superficial sural artery from popliteal or sural artery, divides into median, medial and lateral superficial sural arteries o Flap based on median superficial sural arteries o Flap and pedicle centered over lesser saphenous vein o Landmarks: lesser saphenous vein, sural nerve o Pedicle includes superficial sural artery, sural nerve Saphenous artery branch of descending genicular artery off SFA lateral thigh flap: third perforating branch from PFA (septocutanous branches of descending lateral circumflex fem art and venae), immediately caudad to adductor brevis muscle, pierces insertion of adductor magnus, courses between biceps femoris and vastus lateralis

Rectus femoris and vastus lateralis: lateral femoral circumflex vessels o rectus femoris: lateral circumflex femoral, femoral nerve o vastus lateralis dominant pedicle: lateral femoral circumflex, minor pedicle: lateral genicular artery (can cover acetabulum, groin, perineum, trochanter) TFL: lateral femoral cutaneous nerve and superior gluteal nerve o TFL flap provides best sensate flap for ischial pressure sore Biceps femoris: perforating branches of PFA, sciatic nerve gluteus maximus: superior gluteal, inf gluteal; inf gluteal nerve Gracilis o motor innervation is anterior branch of obturator nerve o gracilis is immediately posterior to the adductor longus o adductor magnus is posterior to the gracilis o medial circumflex femoral from PFA + minor pedicle from SFA groin flap blood supply: superficial circumflex iliac Deep inferior epigastric arises from external iliac gastrocnemius blood supply: sural artery superficial circumflex iliac and superficial inf epigastric arteries have separate origins in 40%, in 4550% they have a common trunk external oblique: upper half intercostals, lower half deep circumflex iliac artery and iliolumbar pec major flap: thoracoacromial artery pedicle of parascapular flap arises from the triangular space and enters the deep surface of the flap o triangular space = triceps, teres major, teres minor, subscapularis o circumflex scapular artery Trapezius: transverse cervical from thyrocervial trunk lateral arm fasciocutaneous flap is based on the posterior radial collateral artery

Skin Disorders Rhynophyma: sebaceous hyperplasia of nasal skin, sequela of acne rosacea, rx tangential excision and healing by 2ndary intention Cutis laxa: nonfunctioning elastase inhibitor results in drooping skin, assoc w/ congenital heart dz, emphysema, PTX, can be candidate for cosmetic surgery Hidradenitis suppurative o Most common organisms in: S. aureus, Viridans strep o Chonic infection of apocrine sweat glands Cutaneous sarcoidosis o Noncaseating epithelioid granulomas o Epithelioid cells containing Schaumann (asteroid bodies) in dermis o Rx: intralesional steroids, oral hydroxychloroquine or methotrexate o Oral steroids with severe lesions or symptomatic involvement of other organs o DDx: Keloids scaterred collagen fibers, no granulomas Neurofibromatosis swirls of fibroblastic cells, collagen, nerve fibers Rhinosporidiosis Rhinosporidium seeberi bacteria, negative cx, sporangia on smear Wegeners granulomatosis intranasal ulcerations, necrotizing granulomatous vasculitis pyogenic granuloma: rapidly proliferative lesion, pedunculated, bleeds easily, typically on eyelids, cheeks, extremities, lips, oral mucosa, tongue, nasal cavity Morphea BCC synthesize type IV collagenase, highest incidence of recurrence o Aka fibrosing or sclerosing Merkel cell carcinoma: dense sheets of oval cells w/ indistinct borders that invade deep dermis

o o o

Rx: excision w/ 2- 5 cm margins Positive for neuron-specific enolase Prophylactic neck dissection

Mongolian spot: dermal dendritic nevus, usually over sacral region, disappears in early childhood Nevus sebaceous of Jadassohn: o Yellow-orange waxy elevated plaque o Usually face or scalp in infants o 10-15% BCC o 19% occurrence of syringocystadenoma papilliferum (benign) Sebaceous carcinoma: arises from sebaceous glands, ocular from meibomian glands, non-occular from hair bearing areas Lentigenes = Skin lesion that results from sun exposure Ephelides: common pigmented freckles, not sun related, normal # melanocytes, increased melanin in epidermal cells Chondrodermatitis nodularis helice o benign lesion of ear in men > 40 yrs o painful erythematous nodule typically involving helix or antihelix o occurs on side pt sleeps o rx excision Seborrheic keratosis: waxy, greasy, pressed-on appearance; generally on face, trunk of older age Syringoma: flesh colored or yellow papule in adolescent, early adulthood, females, often only on lower eyelid Becker nevus is actually a benign cutaneous hamartoma w/ epidermal and or dermal elements Familial dysplastic nevus syndrome o Occurrence of melanoma in 1 or more first- or second- degree relatives o Large numbers of moles o Moles that show distinct histologic features (eg atypical melanocytes) o Increased risk of melanoma o Intense photographic surveillance q 3-4 mo Cylindroma: round, firm, fleshy tumor of scalp; rarely solitary Dermatofibroma: skin tumors of trunk and extremities, < 2cm size, women>men, fibrous papular lesion, characteristically on lower extremities in young adults xanthelasma: disorder of lipid metabolism acrochordoma: skin tag Risk of malignant transformation in actinic keratosis is 10% at 5 yrs Actinic keratosis: 20% go on to SCC, rx with topical 5-FU Bowens disease: o intraepithelial squamous cell carcinoma o both sun exposed and non-sun-exposed areas o solitary , sharply defined lesions w/ red discoloration and plaque o possible causes: UVa light, arsenic, viral infxn, chronic trauma, genetic keratoacanthoma: grow rapidly over several weeks, regress spontaneously over 4-6 mo o excisional bx recommended o initially firm, round, flesh-colored or reddish solitary papules o progress to dome-shaped nodules w/ smooth, shiny surface and umbilicated center w/ keratin plug o common areas: face, neck, dorsal arms o keratoacantoma is subset of SCC Pigmented Nevi o Spitz: head and neck in kids, extremities in adults, difficult to differentiate from melanoma, excise w/ narrow margins, in kids: benign pink lesion w/ multiple brown spots, histo shows nonpigmented spindle cells, epithelioid nevomelanocytes w/ raining down pattern o Blue nevus: small intradermal papular lesion of dermal melanocytes o Mongolian spot: brown flat patches of dermal melanosis, present at birth in sacral area

o Nevus of Ota: flat, brownish blue patch, dermal melanosis in Trigeminal nerve distribution
Nevus of Ito: flat, brownish blue patch in distribution of posterior supraclavicular and lateral cutaneous branches to shoulder, neck and supraclavicular skin o Nevus spilus=caf-au-lait spot (light brown pach) w/ darker speckles within Halo nevus: no premalignant potential, excisional bx should be performed for any halo nevus that becomes enlarged, asymmetric or ulcerated Hutchinsons freckle = lentigo maligna melanoma (within epidermis only), large pigmented lesion w/ malignant potential Increased risk of nonmelanocytic skin malignancies: number of lifetime sunburns, sun exposure during adolescence, sun exposure during childhood, sun exposure at irregular intervals NOT depth of sunburn Toxic epidermal necrolysis syndrome: sloughing occurs at dermal-epidermal junction Purpura fulminans: o severe hemorrhage and skin necrosis assoc w/ DIC o petechial rashes which progress to confluent areas of ecchymosis then necrotic eschar o sepsis o most common assoc organism: Neisseria meningitides o mechanism: endotoxin, liposaccharide-mediated endothelial damage o other organisms: strep pneumoniae, H flu, rickettsia o Indications for Mohs o Basal cell carcinomas: recrrent lesions, anatomically sensitive sites (eyelid margin, medial canthus, nasal ala), morpheaform (sclerosing) type Mohs defect of medial canthus okay to heal by 2ndary intention Indications for Mohs:

Vascular Malformations Vascular malformations AVM bluish discoloration of skin, rapid blood flow, pulsations, temp changes, minimal dermal involvement, bruit or thrill, MRI is first step in work-up, ligation of feeding vessels is contraindicated, pre-op embolization of AVMs targets center of malformation - can be assoc w/ skeletal changes, intraosseous extension & lytic changes in 34% Venous compressibility, fills w/ blood, larger and extends deeper, intertwines w/ neurovascular components Capillary (port-wine stain) abnormal capillaries in dermis, present at birth, no regression, cobblestoning, ectasia, progressive darkening; if in V1-V2 distribution may have ocular or CNS involvement - cobblestoning lesion is capillary malformation Hemangiomas appear after birth, regress; primitive endothelial cell nests

During proliferation circulating 17-beta estradiol increased, binding sites increase, collagenase increases, incr mast cells, plump endothelial cells, multilaminate basement membrane Red macule that wasnt present at birth and enlarges rapidly is likely a proliferative hemangioma and should be observed 80% of hemangiomas are noted in the first month of life hemangiomas are hyperplastic early excision recommended for: lip, tip of nose, perocular Lymphatic clear vesicles, soft and compressible on palp, bony overgrowth Spider angioma arteriolar malformation w/ central blanching arteriole, must obliterate to treat, use laser or electrocautery Upper airway hemangioms: Unilateral subglottic CO2 laser Circumferential lesions oral or intra-lesional steroids, may need trach Lymphatic malformations: 90% noted by age 2 males=females rapid growth caused by cellulitis and respiratory infection 80% have hypertrophy and distortion of facial bones open bite, prognathism, malocclusion bony overgrowth despite soft-tissue resection no proliferative capacity soft and doughy on palpation viral illness can cause enlagement Fillers

Lasers

Restylane: cross-linked, stabilized, 3rd gen hyalurinc acid Hyalform gel: hyaluronic acid Dermalogen: dermis Fascian: fascia lata Isolagen: autologous human skin cells from cultured fibroblasts Zyderm: bovine collagen bovine collagen is most effective injected into the dermis Zyderm, Zyplast: bovine collagen, 3% allergic reactions, test dose 4 wks prior to injection Artecoll = Permanent soft tissue filler made of small, microbeads of polymethylmethacrylate (PMMA) cross-linking hyaluronic acid increases resistance to degradation Noncoherent light source: intense pulsed o High-intensity o Polychromatic energy o 510-1200 nm o Treats: hyperpigmentation, telangiectasias, rosacea, unwanted hair, rhytids, vascular malformations o Adverse effects: crusting, erythema, pupura Type of laser Pulsed-dye laser Nd:YAG or double Q-switched Nd:YAG Er:YAG Use cutaneous vascular lesions, photomechanical, orange and yellow tattoos vascular lesions or removal of hair, tattoos. Black ink, amateur tattoos stimulate collagen production greatest affinity for water (lymphatic malformations), 10x higher than CO2, shorter pulse duration, shorter

Wavelength 585nm 1064 nm 1320 nm 2940 nm

10,600 nm

CO2

duration of exposure, more efficient absorption Photothermal injury, greater skin contraction, longer recovery, risk hyperpigmentation

Erbium:YAG (Er:YAG) laser o treatment of choice for ablative resurfacing of skin o wavelength 2940 nm o decreased dermal heating, minimal long-term contraction of dermis o transudative wound o permanent hypopigmentation in 40% Lasers: o Erbium, 2910 nm: lymphatic malformations o Alexandrite, 755 nm and Diode, 810 nm: removal of hair and blue, green tattoos o Nd:YAG, 532 nm and 585 nm pulsed dye: small vascular lesions (eg capillary malformation), red and brown pigment o 1064 nm Nd:YAG: dark tattoo pigments (blue, black), other dermal pigments o carbon dioxide (10600 nm) and erbium can resurface scared or wrinkled skin o copper vapor, 500-600 nm: red and brown chromophores port wine stain = capillary malformation, treated w/ laser coagulation using flashlamp-pumped pulsed dye laser at 577 nm Nd:YAG for removing foreign bodies embedded in skin, eg road asphalt, carbonaceous material or ink Hair Restoration Donor dominance: hair follicles from different areas of scalp have pre-determined lifespan, therefore use follicles from ares that have longer lifespan, eg occipital scalp o Occurs in all cases Phases of hair growth o Anagen: active phase, lasts 3-5 yrs (85% of follicles) o Telogen: loss of hair shaft (15%) o Balding: shorter anagen, prolonged telogen

If 2/3 of follicular unit transplanted, 30% of follicles will produce new hair Minoxidil works in 33% for Hamilton 6, sagital scalp reduction is indicated before establishing anterior hairline Male pattern alopecia: decreased anagen (active phase), increased telogen (resting phase), more villous follicles o Only cause of male pattern allopecia is inheritance (X-linked autosomal dominance) Chronic telogen effluvium: persistent increased telogen hair shedding, not responsive to surgical hair restoration

Burns Criteria for admission to burn center o 2nd or 3rd degree over > 10% BSA age < 10 or > 50 o 2nd or 3rd degree over .> 20% BSA in any age o Burn of face, hands, feet, genitalia, perineum, skin over major joints o 3rd degree over > 5% BSA an age o Inhalation, electrical, chemical lightening o Significant medical hx (DM, CAD) o Other trauma o Special social or emotional needs or requires long term support Immunolgic response to burns: o Impaired cell mediated immunity, impaired T cell function Delayed allograft rejection, suppressed graft vs host response, skin hypersensitivity

Suppression of circulating T cells, redistribution w/in blood and tissue Decreased IgG IL-7 increases decreased B cell proliferation o activation of supressor T cells, decr production of helper T cells o decreased leukocyte function : increased phagocytosis, but decreased intracellular killing o decreased fibronectin o decreased circulating complement, but increased complement activation Acute burn injury o Decreased cardiac output o Decr plasma vol o Incr SVR o Release of angiotensin II, catechol, neuropeptide Y, vasopressin o Incr cell water content o Elevated glucose Curreri formula : o 25 x body wt (kg) + 40 x %BSA burned o o o o Parkland formula includes 2nd and 3rd deg burns most common cause of death in burn patients= pneumonia Reactions of topical burn agents o Silvadene neutropenia, thrombocytopenia o Mafenide acetate metabolic acidosis o Silver nitrate brown staining, methemoglobinemia Zones of burns: o Zone of coagulation: irreversible uniform necrosis of cells o Zone of stasis: microthrombi, potentially reversible, antibodies against neutrophils can block adherence to vessel wall (animal studies), monoclonal antibodies can inhibit neutrophil adhesion and limit depth of burn o Zone of hyperemia: vasodilation, increased blood flow, minimal cell injury burn to oral commissure should be splinted for at least 6 months to prevent microstomia anhydrous ammonia is alkaline, causes denaturing of proteins Topical 5-aminolevulinic acid converted to protoporphyrin IV, activated by pulsed-dye laser Most predictive peripheral blood marker of fatality are erythroblasts

Pressure Sores Pressure sore staging Stage Description I Skin intact, erythema II Blister or break in dermis into subcutaneous fat III Subcutaneous destruction into muscle IV Bone or joint involvement Recurrence rate for pressure sores after flap coverage is 80% at 1 year Highest level at which bony debridement can be performed on sacrum w/o entering dural space: juncture of S 2-3, conus medularis at L2 Most common complication after ischiectomy in paraplegic is contralateral ischial pressure ulcer (28%) Best option for sacral pressure ulcer in ambulatory pt is superior gluteal artery perforator flap For patient w/ spasicity and pressure sores, intrathecal administration of baclofen via implantable pump will reduce recureence mc cause of death in paraplegic w/ chronic pressure sores: renal failure Treatment for trochanteric ulcer with communication into joint is resection of femoral head (Girdlestone)

Miscellaneous Calciphylaxis: increased parathyroid hormone, normal serum calcium, decreased protein C topical vitamin E increases incidence of papular and follicular dermatitis Prostaglandins TXB2 and PGF2a induce microvascular thrombosis in frostbite injury Hemophilia: o Factor VIII deficiency o 80-100% of normal levels required before major operations o maintain > 30% normal for 2 wks post-op o half life 8-12 hrs partial thickness neck wounds left open for > 3 wks results in hypertrophic scarring in 78% Dextran 40: o Decreases factor VIII and vWF o Increases electronegativity of platelets o Modifies structure of fibrin o Volume expander o Inhibits alpha-2 antiplasmin Dermabrasion: o Controlled mechanical abrasion of epidermis and variable dermis o Useful for scars, facial rhytids, skin deformities o Induces collagen synthesis o Wound repair begins in remnant dermal appendages o Endpoint is reticular dermis: brisk, confluent bleeding on coarse tissue background o Sparse, punctuate bleeding at superficial papillary dermis o Re-epithelialization occurs in 7-10 days, erythema persists up to 6 wks Botox mechanism: inhibition of release of acetylcholine Z-plasty gains Zplasty Gain 30 deg 25% 45 50% 60 75% 75 100% 90 120% Outer limbs of Z-plasty should be parallel to minimal tension lines Biologic dressings o Apligraf: neonatal epidermal keratinocytes, dermal fibroblasts, bovine collagen o Biobrane: nylon, silicone fabric, porcine collagen o Integra: bovine collagen, shark-derived chondroitin-6 sulfate, bilayer of Silastic epidermis, allows for thinner skin grafts o Transcyte: neonatal dermal fibroblasts on thin, semipermeable membrane of silicone bonded to nylon mesh and bovine collagen Integra: o Advantages: large quantities, simplicity, reliability, pliability, cosmetic o Disadvantage: longer healing time until final wound coverage o Integra - top silicone layer can be removed in 21 days Alginate dressings: absorb exudates, provide moist environment Rabies rx: o Not previously vaccinated: rabies immunoglobulin into wound margin, vaccination into deltoid x 5 doses o Previously vaccinated: no RIG, vaccination into deltoid x 3 doses Most likely mechanism of silicone sheeting: increasing static electronegative field

Tretinoin (retinoic acid) o Accelerates reversal of skin damage caused by sun exposure o Inhibits binding of AP1 transcription factor to DNA o Decreases activation of collagenase, gelatinase, stromelysin o Thins stratum corneum, reverses cellular atypia, thickens epidermis o Collagen synthesis increased o Melanin dispersed more evenly o Increases hyaluronic acid and returns of granular layer thickness o Increase in dermal mucin

HAND AND EXTREMITIES Anatomy Hand embryogenesis o Development begins in 1st 4 wks gestation o 5th wk, hand recognizable o Apical ectodermal ridge defines growth and differentiation of new limb during embryogenesis, arises from Wolffian ridge o Phalanges form from cell death in web spaces o Digits defined 8th wk, fingernails 17 wks Capitate is visualized earliest on xrays o Capitate and hamate birth-age 6 mo o Triquetrum age 6 mo to 4 yrs o Lunate age 6 mo to 9.5 yrs o Trapezium age 1.5 yrs to 10 yrs o Trapqzoid age 2.5 yrs to 5 yrs o Scaphoid age 2.5 yrs to 9 yrs o Pisiform age 6.5 yrs to 16.5 yrs medial antebrachial cutaneous nerve is adjacent to basilic vein sural nerve is standard graft for larger nerves eg. Median, ulnar plantaris is in superficial posterior compartment (soleus, gastroc) medial plantar artery is between the abductor hallucis and flexor digitorum longus tendons triangular space: long head of triceps, teres major, teres minor (circumflex scapular artery) intrinsic tightness indicated by: resistance to flexion of PIPJ with extension of the MPJ, full flexion of MP joint allows for greater flexion of PIP joint FPL and FDP are most sensitive to compartment syndrome in forearm anatomic snuff box: volar border = abductor pollicis longus, extensor pollicis brevis; dorsal border = extensor pollicis longus tendon motor fasciculus of median nerve is volar and radial in orientation w/ respect to the rest of the nerve motor fascicular group of ulnar nerve is dorsal and ulnar to sensory group at the wrist; continues in Guyons canal which is split in a prox zone 1 where the motor fascicles lie deep (dorsal-ulnar)

to the sensory fascicles within the nerve at this level. In zone 2, the deep motor branch is deep and radial to the superficial sensory branch. In the arm, they are between
the sensory fascicles to dorsal sensory nerve branch Total active range of motion= active motion of (MCP + DIP + PIP) extension deficit o Normal = MP (90) + PIP (110) + DIP (70) = 270 Merkel cell neurite complex transmits constant touch and pressure Superficial inferior epigastric artery flap: o SIEA arises from intersection of inguinal ligament and femoral artery Innervation of the foot: o Dorsal superficial peroneal nerve o 1st web space deep peroneal nerve (travels w/ AT artery) o Lateral sural nerve o Medial saphenous nerve (not affected by compartment syndrome of leg) o Plantar tibial nerve (travels w/ PT)

For harvest of posterior interosseous artery flap, harvesting cuff of EPL can preserve blood supply to bone Posterior interosseous nerve: found in floor of 4th extensor compartment beneath EDC and EIP, travels proximally beneath EPL Normal component of fascia surrounding neurovascular bundles are: Clelands, Graysons, lateral digital sheet, retrovascular band Midpalmar space boundaries o Flexor tendons o Metacarpal bone o Interosseous fascia o Septum from 3rd MC to FDP sheath o Hypothenar eminence Thenar space borders: o Vertical septum betwn 3rd MC and LF o Radial edge abductor pollicis brevis tendon Index finger drains into thenar space Long, ring, small fingers drain into midpalmar space Radial and ulnar bursae communicate by Paronas space Carpal tunnel contents: FDS, FDP, FPL Appropriate positions for arthrodesis PIP joints Finger Angle of flexion Index 40 degrees Long 45 Ring 50 Small 55 MCP joints Thumb Index Long Ring Small 15 degrees 25 30 35 40

Congenital hand inhibition of physiologic cell death in interdigital areas during embryogenesis causes syndactyly cleft hand: hypoplasia of ectodermal ridge polydactyly: hyperplasia of ectodermal ridge phocomelia: defects of bone and upper extremity, severe intercalary or longitudinal deficiencies, assoc w/ thalidomide

camptodactyly = bent finger, developmental isolated flexion contracture of the PIPJ resulting in AP deviation of the finger, typically bilateral and usually little finger; abnormal insertion of lumbrical or superficialis tendons - no rx necessary, observation Treatment for camptodactyly (nontraumatic flexion deformity of PIPJ bilaterally) o < 20 deg extension of PIP observe o > 30 deg terminal extension deficit surgical release of lumbrical and superficialis tendon +/- release attachment of accessory collateral ligaments to volar plate Congenital trigger thumb: o 1 in 2000 o Fixed flexion deformity of thumb o Thickening of tendon Nottas node o If < 3 yrs old spontaneous resolution in 30% o Rx: A1 pulley release if no resolution by age 3

Congenital clasp thumb: absence of EPB and EPL tendons, characterized by extreme flexion of MCP joint and adduction of thumb into palm Symphalangism = congenital stiffness of finger usually involving PIP joint, actively and passively stiff in extension clinodactyly = deviation of a digit in radioulnar direction caused by abnormally shaped bone, middle phalanges most commonly involved; autosomal dominant, bilateral assoc w/ Down syndrome, delta phalanx; rx excision and wedge osteotomy o delta phalanx: characterized by a triangular or trapezoidal shaped bone w/ C shaped epiphyseal plate - proximal epiphysis curves around from its transverse orientation to a longitudinal one from proximal to distal along one side of the phalanx, thus forming a "C"' - this results in a trapezoidal phalanx; - longitudinal growth is impossible and angulation inevitable symbrachydactyly = sporadic, inherited central hand defect characterized by shortened, syndactylous digits Ectrodactyly: partial or total absence of 1 or more fingers o Typical: absence of 3rd ray > 2nd > > 4th o bilateral , assoc anomalies (cleft lip, palate, congenital heart, upper and lower extr deformities, Syndactyly) familial o Atypical (symbrachydactyly): deficient rays unilateral, nonfamilial, digital nubbins arthrogryposis = limited active and passive motion in all joints of the upper ext radial club hand: partial or total absence of radial or preaxial border of upper extremity, range from thumb hypoplasia to varying degrees of absence of radius, resulting in radial deviation of the hand Complete absence of the radius (type IV radial club hand): associated w/ absent radial artery, treatment is centralization of ulna into carpus followed by pollicization of index finger abnormalities assoc w/ radial dysplasia o Holt-Oram syndrome o Fanconi anemia (pancytopenia, Mitomycin testing) o TAR (thrombocytopenia-absent radius) o Imperforate anus o VATER o Robert syndrome: tetraphocomelia, brain and craniofacial abnormalities Madelungs deformity: congenital disorder of wrist apparent in late childhood, shortening of radius, palmar subluxation of carpus, prominence of ulnar head Syndactyly is an isolated abnormality in most o 1 in 2500 o Familial inheritance 10-40% o boys:girls 2:1 o Complete vs. incomplete o release before 18 months (12-18) o Complex (bone involved) vs. simple Syndromes with hand involvement: o Aperts: bilateral, symmetric, complex syndactyly w/ shortened fingers, generalized acne, prominent bregmaic eminence or bump (junction of sagital and coronal sutures) o Carpenters syndrome: simple syndactyly, shortened fingers, preaxial polysyndactyly, broad thumbs, craniosynostosis o Pfeiffers: mild parital syndactyly, broadened, deviated thumbs, severe midface hypoplasia o Polands: unilateral findings, absence of pec, hypoplasia of upper extremity, simple syndactyly and shortened fingers Amniotic constriction band syndrome: rx is excision of bands and Z-plasty closure, observation or delayed release in less severe cases, no known genetic transmission Radial club hand assoc w/ Fanconi anemia o Thumb hypoplasia, shortened forearm w/ radial curvature o Autosomal dominant

Other assoc conditions: VATER, Holt Oram (cardiac septal defects), TAR (thrombocytopenia, absent radius syndrome) o Fanconi: pancytopenia, mytomycin testing Thumb-in-palm deformity o Type I: simple adduction contracture of metacarpal from spasticity of adductor and 1st dorsal interosseous o Type II: includes flexion deformity of MP joint caused by spasicity of FPL o Type III: simple adduction contracture of MP + hyperextension of MP from spasticity of adductor, 1st dorsal interosseous and EPB tendon, cause hyperextensibility of MPJ o Type IV: like type I, + spasticity of FPL o Treatment: release of spastic muscle and joint stabilization Typical cleft hand deformity o Longitudinal deficiency dysplasia of central portion of hand o Autosomal dominant o 5 categories based on degree of ray absence and thumb space hypoplasia o V shaped cleft, suppression of central digit, minor syndactyly of ulnar border digits o Assoc w/ cardiac, renal, pulm, ocular defects, clefts o EEC syndrome ectrodactyly, ectodermal dysplasia, cleft lip/palate o Snow-Littler procedure transposition of palmar-based cleft flap with index ray to close cleft Atypical cleft hand o Sporadic o Part of symbrachydactyly sequence o Broad, flat cleft hand w/ finger nubbins o

Modified Blauth classification of hypoplastic thumb I Minimal shortening and narrowing no rx II Thumb-Index web space narrowing, Hypoplastic intrinsic thenar muscles, Metacarpophalangeal joint instability release 1st web space, stabilization procedure for MP, tendon transfer for abduction or opposition III A Type II features, plus extrinsic tendon abnormalities and hypoplastic metacarpal, stable carpometacarpal Huber transfer (transfer hypothenar muscle to recreate thenar) III B Type II features, plus extrinsic tendon abnormalities and partial metacarpal aplasia, unstable carpometacarpal IV Floating thumb V Absent thumb Type IIIB , IV, V pollicization during pollicization, 1st dorsal interosseous becomes the new abductor pollicis brevis EDC becomes APL EIP becomes EPL 1st palmar interosseous becomes adductor pollicis Conditions associated w/ congenital absence of thumb a) spinal abnormalities (VATER) b) cardiovascular (Holt-Oram syndrome-upper limb dysplasia, ASD, clavicular hypoplasia) c) hematopoietic anomalies (Fanconi anemia, thrombocytopenia-absent radius [TAR] syndrome) d) Renal abnormalities (VATER) e) GI anomalies f) Cornelia de Lange syndrome distinctive facial appearance, prenatal and postnatal growth deficiency, feeding difficulties, psychomotor delay, behavioral problems, and associated malformations that mainly involve the upper extremities

g) h) i) j) k)

l) m)

Hand-foot-uterus syndrome Trisomy 18 Brachydactyly Rubinstein-taybi syndrome mental and growth retardation, short broad thumb, typical facies Apert syndrome Carpenter syndrome acrocephalopolysyndactyly Myositis ossificans extra-skeletal ossification that occurs in muscles & other soft tissues

1. Thumb Duplication :
a. autosomal dominant, black>white b. treatment involves ablation and transfer of abductor pollicis brevis c. Wassel classification Bifid distal phalanx Skeletal union of all or portion of distal phalanx Duplicated distal phalanx No skeletal union of distal phalanx Bifid proximal phalanx Duplicated proximal phalanx Most common (50%) Bifid metacarpal Duplicated metacarpal Triphalangeal component Assoc w/ ASD, VSD, transposition, PDA, hypoplastic anemia, Holt-Oram, Juberg-Hayward syndrome, Blackfan-Diamond anemia, Fanconi anemia

I II III IV V VI VII

Hand tumors chondromixoid fibroma: benign cartilaginous tumor rarely in upper extr, radiolucent lesion w/ small sclerotic rims separating tumor from lamellar bone osteosarcoma: rare in hand, malignant, varying bone erosion and periosteal reaction Chondroma (extraosseous tumor) and enchondromas (endosteal tumors): common bone tumors typically in metacapals and phalanges; xrays radiolucent, thinning of cortex, speckled calcifications; rx curettage w/ bone grafting giant cell tumor of bone: multifocal hand tumor, xray: irregular, expansile radiolucent tumor of epiphyseal region; rx ray resection or en bloc removal and bone grafting; recurrence common multiple enchondromatoses (Olliers diease): larger than solitary enchondromas, assoc w/ axial skeletal deformities, increased risk for malignant degeneration osteochondroma: solitary or autosomal dominant, assoc w/ deformity and impaired motion; rx fesection and reconstruction Enchondroma: cartilaginous tumor, 2nd or 3rd decade, incidental finding or pathologic fracture, scalloped, lytic lesion in medullary canal; benign clusters of hyaline cartilage surrounded by lamellar bone w/ varying calcification o conditions w/ enchondromas: Ollier disease, multiple enchondromatosis Maffucci syndrome (multiple enchondromas and subcutaneous hemangiomas) o Rx curettage of lesion, bone grafting

osteoid osteoma: painful bone tumor, pts < 40 yo, pain relieved w/ NSAIDs; xray shows radiolucent zone w/ cortical sclerosis (target-like lesions); recurrence rare o pain in phalanx at night, relieved by NSAIDs, xray radiolucent zone w/ dense nidus surrounded by cortical sclerosis: most commonly osteoid osteoma, rx complete excision mucous cyst: middle age or elderly, swelling and nail deformity (nail grooving common), xray shows osteoarthritis and osteophytes Benign hand tumors o Glomus tumor: benign hamartoma of neuromyoarterial receptor which regulates skin temp and blood flow, typically subungual, < 1 cm, pinpoint tenderness and cold intolerance, bright on T2 MR

Epidermal inclusion cyst: nontender masses partially formed following trauma, typically on palmar hand and digits o Ganglion cyst: most common, mucoepidermoid degeneration of joint capsule Dorsal 60-70%, scapholunate ligament Volar 20%, radiocarpal joint, scaphotrapezial joint o Giant cell tumor (localized pigmented villonodular synovitis): lobulated, nontender, subcutaneous mass over finger; typically on palmar surface of wrist, hand, fingers in women 30-50 yrs; commonly presents as ndular thickening over flexor tendon sheath o Neurilemmomas: most common solitary tumor of neural cell origin, composed of Schwann cells; causes asymptomatic nodular swelling w/o sensory or motor abnormalities turret exostosis: benign extracortical bony proliferation that results from injuries to the dorsum of the fingers SCC with involvement of bone requires amputation Ganglion cysts of DIPJ are assoc w/ arthritic changes of osteophyte, rx is debridement of osteophyte, cyst resolves on its own Rapidly growings skin lesion in immunosuppressed = keratoacanthoma o

Nerve Entrapment ulnar nerve in hand: adductor pollicis, deep head of flexor pollicis brevis, palmaris brevis, abductor digiti minimi, flexor digiti minimi, opponens digiti minimi, all interosseous median nerve: abductor pollicis brevis, opponens pollicis, 1st and 2nd lumbricals, superficial head of flexor pollicis brevis Anterior interosseous syndrome (median nerve): o poorly defined pain in proximal forearm relieved w/ rest o pure motor deficits o weakness or paralysis of FDP of index and long fingers, FPL, pronator quadratus

Posterior interosseous nerve syndrome (radial nerve): o weakness and pain in forearm, absence of sensory loss; o weakness of extension of MCP of fingers and IP of thumb o weakness of thumb abduction and wrist extension; deviation of wrist radially Wartenbergs syndrome: radial nerve is compressed beneath edge of brachioradialis at level of wrist o Pain on dorsoradial surface of hand and distal aspect forearm o burning, numbness or tingling over the dorsal aspect of the first web space o Sensitivity to percussion o Tinels sign over superficial radial sensory nerve, no weakness o Avoid wearing jewelry or bracelets Radial tunnel syndrome: pain and tenderness over mobile wad (radial tunnel) w/ extension, supination against resistance, passive flexion and pronation of wrist o pain localized just below elbow in extensor mass and along course of radial nerve o no sensory or motor loss o compression of the deep branch of the radial nerve, or posterior interosseous nerve, within radial tunnel o compressing structures are the vascular leash, the arcade of Frohse and proximal edge ECRB tendon Ulnar nerve entrapment (cubital tunnel syndrome) o numbness in dorsoulnar aspect of hand, small finger, ulnar aspect of ring finger, weakness in FDP of ring and small finger, first dorsal interosseous o Arcade of Struthers (most common site of entrapment in arm) o Band of Osborne (cubital tunnel) o Medial intermuscular septum Ulnar nerve compression in Guyons canal (wrist) relese pisohamate and volar capal ligaments to distinguish ulnar nerve compression at wrist vs. elbow, check for sensation over dorsolulnar hand, supplied by dorsal branches from ulnar nerve proximal to Guyons canal Wartenberg sign: loss of adduction of small finger toward ring finger with fingers in extension

ulnar nerve transposition length gained o 3 cm in arm o 2 cm in forearm o 1-2 cm distal forearm and wrist o Anterior transposition at elbow involves releasing medial intermuscular septum Pronator syndrome: median nerve compression in proximal forearm causing sensory and motor deficit similar to carpal tunnel syndrome; sensory sx usually more proximal; sx reproduced w/ active elbow flexion o affects radial half of FDP, FPL differentiates from CTS o Pain and paresthesia in forearm, worse w/ activity o Decr sensation, paresthesia in radial side of palm, base of thenar eminence, thumb, index, long, radial side ring Potential sites of median nerve compression in forearm: o Median nerve entrapment beneath ligament of Struthers (proximal), lacertus fibrosus, pronator teres, arch of FDS o Compression at ligament of Struthers (bicepital tendon from antebrachal fascia): pain worse w/ flexion of elbow against resistance o Compression at lacertus fibrosus: sx worse w/ active flexion of elbow w/ forearm in pronation o Compression by pronator teres: pain w/ resisted pronation of forearm during wrist flexion o Compression by superficialis: pain w/ resisted flexion of FDS of long finger Effort -associated carpal tunnel syndrome caused by inflammation of lumbricals o Origin from radial side of FDP, except 3rd lumbrical which originates ulnar side LF, radial side RF o Insertion: radial sagital band o Innervation: median (1st, 2nd), ulnar (3rd, 4th) intersection syndrome: pain syndrome localized to distal forearm at intersection of 1st extensor compartment (APL and EPB) and 2nd extensor compartment (ECRB, ECRL) o pain, swelling 4 cm proximal to wrist, crepitus in distal forearm proximal to Listers tubercle o tightness of retinaculum over first and second dorsal compartments o treatment: release second dorsal compartment Tarsal tunnel syndrome o Compression of medial and lateral plantar branches of tibial nerve w/in fibro-osseous tunnel posterior to medial malleolus o Burning, numbness, paresthesias plantar surface of foot or beneath metatarsal heads o Worse at night o Clawing of toes 2ndary to weakness of intrinsics Mortons neuroma o Chronic compression of common plantar digital nerve w/in metatarsal heads o Pain radiates from 3rd and 4th metatarsal heads into toes o No motor findings

Dupuytrens contracture: Graysons ligament, lateral digital sheath, natatory ligaments, superficial palmar fascia are involved (Clelands and Landsmeers ligaments are not) Spiral cord = spiral band, pretendinous band, lateral digital sheath, Graysons ligament, vertical band Contracture of DIPJ caused by retrovascular cord contracture of PIPJ caused by central, lateral, spiral cords contracture of MPJ caused by pretendinous cords contracture of spiral cord displaces neurovascular bundles Natatory cord causes adduction contracture

Normal structure diseased cords o pretendinous band central cord o central digital sheath lateral cord o pretendinous, spiral band, latral digital sheath, Graysons spiral cord Normal fascia around neurovascular bundle: Cleland, Grayson, Lateral digital sheet, retrovascular band Dupuytrens diathesis: aggressive form of Dupuytrens contracture assoc w/ knuckle pads, involvement of plantar fascia and Peyronies disease; earlier onset, more rapid progression, bilateral, radial side of hands Dupuytrens nodules common in pts w/ h/o plantar fibromatosis, if asx observe, if painful, inject w/ steroids Collagenase for Dupuytrens is effective for MCP contractures, not PIPJ

Soft Tissue Coverage Hand, Lower Extremity pedicled groin flap blood supply = superficial circumflex iliac Distal third thumb wound w/ exposed bone at distal phalanx: cover with volar advancement (Moberg) flap (advancement > 1.5 cm is difficult) Atasoy-Kleinert flap: homodigital V-Y advancement of volar pulp tissue, contraindicated for oblique tip amputations Full-thickness skin grafts have better sensory return than STSG for fingertip wounds coverage of avulsion injury of thumb from tip to IP joint best with kite flap (neurovascular flap from dorsal soft tissue of proximal phalanx of index finger) 3 yo with fingertip amputation can be treated w/ composite grafting of fingertip Antecubital fossa wounds can be covered with brachioradialis flap, blood supply from radial recurrent artery osteocutaneous radial forearm flap: fascioperiosteal perforators between brachioradialis and FCR Pt with 12 cm bone defect best managed w/ contralateral free vascularized fibula graft heel wounds: flexor digitorum brevis muscle flap Sartorius blood supply: superficial circumflex iliac artery from SFA lateral femoral circumflex (profunda): rectus femoris, TFL, vastus lateralis medial femoral circumflex (profunda): gracilis Great toe flap in toe-to-hand transfer blood supply: first dorsal metatarsal artery from dorsalis pedis Kite Flap (First dorsal metacarpal artery flap) - Exposed tendon over dorsal IP of thumb o Based on 1st dorsal metacarpal artery: within fascia of 1st dorsal interosseous muscle o Axially patterned, based on terminal branch of radial artery after exits snuff box o Borders: APL & EPB (volar), EPL (dorsal) o Up to 4 x 3 cm o Sensory flap w/ superficial radial nerve branch and dorsal digital nerve branch o Preferred to Littler flap

Litler flap:

o o
o

Neurovascular island flap Based on 3rd common neurovascular bundle Signficant cortical reorientation needed Necessary to ligate proper digital artery to radial aspect small finger

Acquired hand disorders Reflex sympathetic dystrophy (complex regional pain syndrome): progressive complex pain, swelling, stiffness, discoloration of affected part due to vasomotor instability; also hyperhidrosis, osteoporosis, trophic changes o Risk factors for complex regional pain syndrome, injuries to: Upper ext Spinal cord Brain Peripheral nerves Complex regional pain syndrome (aka reflex sympathetic dystrophy) o Type I: no neve injury o Type II: post-traumatic after identifiable nerve injury o Pts age 30-50, smokers, females o Most common injury in type I is distal radius and ulna fx o Most common injury in type II palmar cutaneous branch, superficial radial nerve, dorsal branch ulnar o Pain out of proportion, joint stiffness, discoloration, atrophy, vasomotor and autonomic dysfunction o Allodynia, hyperpathia, changes in nail and skin texture, abnormal sweating, piloerection o 3 stages: swelling, warmth, hyperhidrosis brawny edema and trophic changes glossy, cool dry skin w/ stiffness o Diagnosis:

3rd phase of 3 phase bone scan shows diffuse increased periarticular activity Thermography elevated temp Resting sweat output increased Response is positive to iv phentolamine (alpha antagonist)

Traumatic Boutonnieres deformity can be splinted w/ PIP in extension, DIP free; can be done as late as 6 wks after injury Volkmanns contracture: fibrosis of flexors; supracondylar humerus fx; typically flexion at wrist, flexion and adduction of thumb, extension of MP joints, flexion of PIP and DIP o Volkmanns ischemic contracture decompress median nerve intrinsic plus deformity (contracture of intrinsic muscles): flexion at MP, extension at PIP Pincer or trumpet nail deformity: o cause unknown, results in progressive pinching of distal fingertip soft tissue causing pain; o rx is lateral elevation of nail matrix and dermal autografting Boutonniere deformity o Caused by central slip disruption o Stage 1: passive extension of PIP joint; rx splint PIP in extension 6-8 mo o Stage 2: joint contracted and cant fully extend o Stage3: degeneration of joint Tightness of ligament of Landsmeer can produce hyperextension of DIP + PIP flexion contracture causes boutonniere Swan neck deformity o PIP volar plate injury w/ hyperextension, dorsal displacement of lateral bands dorsal to axis of PIP joint rotation

Mallet finger injury in pt w/ ligamentous laxity, w/ all extensor force secondarily transferred to PIP joint and joint pulled into hyperextension because of laxity Palmar fibromatosis and arthritis associated w/ ovarian cancer get abdominal CT Hypothenar hammer syndrome: thrombosis of ulnar artery in Guyons canal, work-up w/ angio; characterized by pain near hook of hamate, paresthesias and decrease in digital temp of ring and small fingers o

Miscellaneous hand best nerve graft for digital nerve is terminal branch of posterior interosseous nerve for comminuted bone, shortening can allow end-end nerve repair w/o tension o shoulder abduction increases median nerve length 2.5 cm, ulnar nerve 2 cm o elbow flexion increases median, ulnar nerves by 4 cm most common cause of pathologic fracture in age 10-30 is enchondroma sickle cell dactylitis: swelling of hands, feet and shoulders EPL rupture assoc w/ distal radius fx after frostbite, angular deformity of the digits can occur in kids from premature closure of the phalangeal epiphyses post-tourniquet nerve palsy, radial nerve most common, most resolve within 6 months Quadriga effect: excess distal pull on one profundus tendon decreases force and amplitude of all tendons longitudinally bracketed epiphysis: growth plate is reverse C-shape; assoc w/ delta phalanx Burns that havent healed by 21 days after initial injury assoc w /significant risk for hypertrophic scarring and contracture, should be tangentially excised to level of punctuate bleeding release of check rein ligaments indicated for flexion contractures Initial rx for spasticity following brain injury should be botox injection, then surgery if that fails Scleroderma o Soft tissue calcium deposits o Ulcerations on fingertips, digital ischemia, flexion contractures, erosion of proximal phalanges at DIPJ, focal entrapment neuropathy o Rx: calcium channel blockers, NSAIDs, penicillamine irrigation w/ 1:1000 dilution of 1% povidine-iodine is bacteriocidal and non-toxic to fibroblasts Treatment for chemical burns: o Hydrofluoric acid calcium gluconate gel o Phenol mineral oil o Creosol polyethylene glycol o White phosphorous irrigation w/ water Extravasation of 100 ml iv contrast assoc w/ increased incidence of compartment syndrome, therefore if > 100ml extravasates, check compartment pressures After release of longstanding flexion contractures, stretching of digital arteries can cause ischemia C5 quadraplegia, elbow extension is most useful to restore transfer deltoid or bicep-to-tricep Primary advantage of wrist disarticulation is preservation of DRUJ which allows pronation and supination Do not exanguinate arm if neoplastic tumor, elevate and compress brachial artery for 1 min, then inflate tourniquet PIPJ flexion inhibited when MP joints fully flexed may result from intrinsic tendon tightness, consider release of lateral bands management of extensor tendon tightness is release of central slips (inability to flex PIP w/ maximal flexion of MP, but ability to flex w/ MP extended) extension of PIPJ on attempted flexion of finger = lumbrical plus deformity resulting from proximal migration of lumbrical and tension on lumbrical transmitted through radial lateral band; rx is division of lumbrical tendon Paradoxical extension of PIP join following DIP amputation caused by migration of lumbrical proximally when attempting to make fist, this exerts tension on extensor mechanism causing extension, treatment is dividing lumbrical muscle For type III avulsion, use of adjacent digital artery for revasc better than vein graft Inability to fully actively extend DIP with PIPJ passively flexed indicates intact central slip

Threshold testing: light touch, Semmes-Weinstein monofilament, 256 cycles-per-sec tuning fork, vibrometry True hand dominance develops at 18-24 months

Hand Infections Chonic paranychia: o Most commonly candida albicans o Oral and topical antifungals o If persists w/o source, excise thickened dorsal nail roof (marsupialization) Most common cause of septic arthritis of hand is S. aureus Onychomycosis o Fungal infection of fingernail o Cause of dystrophic nail in 50% o Rx: terbinafine and itraconazole x 6wks Most sensitive indicator of flexor tenosynovitis is pain on passive extension early flexor tenosynovitis within first 24-48 hrs after onset of sx can be rxd w/ iv ABx and splinting Collar button abscess: communicates from dorsal to volar web space via palmar fascia or lumbrical canal Rx for herpetic whitlow = dry dressings Definitive test for osteo is bone bx and culture Tendon Transfers tendon transfer for high median and ulnar nerve paralysis: extensor indicis propius to FPL Tendon transfers for high radial nerve palsy o Wrist extension: pronator teres to ECRB o Finger extension: FCR, FCU or FDS (long, ring) to distal EDC o Thumb extension: palmaris longus or FCR to EPL Boyes sublimis transfer: FDS of long finger transferred to EDC tendon of long, ring and small fingers; plus FDS of ring transferred to EIP and EPL, FCR to adductor longus and EPB Tendon transfer for spastic cerebral palsy: FDS to FDP Distal ulnar nerve palsy and clawing deformity: ECRL w/ tendon graft to FDP to increase power High ulnar nerve palsy: Brand transfer o ECRL prolonged w/ tendon grafts o Inserted into radial lateral bands o Restores MP flexion, PIP extension o Improves integration of MP and IP motion Zancolli lasso o Transfer of FDS tendon around A2 pulley o Moves clawed fingers into more functional position o Doesnt add power grip Moberg procedure: o Restores thumb key pinch o Annular ligaments of FPL tendon released allowing bow-stringing o Dorsal tenodesis of EPL tendon to dorsal aspect thumb metacarpal o IP joint of thumb fused in extension o Results in contact btwn thumb pad and radial aspect index finger w/ wrist extension Opponensplasty o Camitz: palmaris longus tendon w/ palmar fascial extension to tendon of abductor pollicis brevis o FDS of middle or ring finger o ECU, EIP, EDM Most appropriate for low median nerve palsy is EIP to prox phalanx o Huber: abductor digiti minimi (usually for congenital hypoplastic thumb, Blauth II)

Rheumatoid and Osteoarthritis Rheumatoid arthritis with pain and catching of finger and locking with attempted flexion, palpable nodule in palm: rx is flexor tenosynovectomy and excision of flexor tendon nodule; four types of trigger finger in RA: o Type I: small localized area of disease w/ catching of tendon w/ flexion o Type II: digital tenosynovitis; flexor tendon nodules in palm cause locking o Type III: nodule in FDP in region of A2 pulley causes finger to lock in extension o Type IV: generalized tenosynovitis and limited motion o Flexor tenosynovectomy w/ excision of nodule is indicated in all types of tenosynovitis and triggering most common hand deformity in juvenile rheumatoid arthritis: loss of flexion of IP joint (also loss of flexion and radial deviation of MCP, swan neck and boutonniere, spontaneous tendon rupture rare) adults with RA: radial deviation and supination of carpus, MCP joints subluxed palmarly and deviated ulnarly intrinsic tightness causes flexion of MPJ w/ extension of PIPJ o other findings: attenuation of sagital bands, capsule, collateral ligaments due to synovitis Basal joint arthritis: o Pain at base of thumb worse w/ pinch, grasp, lifting or twisting o Difficulty opening jars, buttoning clothes o Tenderness increased w/ direct compression and axial loading o Surgery: trapeziectomy, reconstruction of volar beak ligament, tendon interposition arthroplasty Most common tendon rupture in RA: EPL Treatment of trapeziometacarpal arthritis in young laborer is arthrodesis In rheumatoid arthritis patients, swan-neck deformity is caused by tightness of intrinsic tendons, in combination w/ subluxation of MP joints caused by synovial hypertrophy o If passively correctable, treatment options include: FDS tenodesis, intrinsic release and silver ring splints, oblique retinacular ligament reconstruction, PIPJ dermodesis o If significant stiffness and end stage joint involvement: PIPJ replacement arthroplasty Darrach resection: a. For treatment of DRUJ arthrosis, advanced rheumatoid arthritis of ulnocarpal joint b. Can increase supination, pronation of hand c. Sx: Pain and decreased rotation of wrist d. excise of distal 1-2 cm of ulna (just proximal to the sigmoid notch) e. if the distal ulna appears unstable, it may be stabilized w/ a distally based strip of ECU tendon f. complications include: instability of ulna, painful subluxation of ECU, palmar subluxation or ulnar translation of carpi, radio-ulnar impingment, can lead to extensor tendon rupture Basilar joint arthritis: a. Attrition of volar oblique ligament b. Loss of abduction of thumb c. Osteophyte migration between 2nd and 1st metacarpal d. Subluxation of 1st metacarpal on trapezium Pts w/ rheumatoid arthritis most commonly get attritional rupture of the flexor pollicis longus > FDP IF > FDS IF, FDP LF a. rupture of extensors occurs 2ndary to dorsal subluxation of distal ulna, extensors rupture from ulnar to radial pattern

Traumatic Hand, LE post-traumatic joint arthritis: best treatment if motion required is silicone implant arthroplasty, arthrodesis decreases pain, but doesnt allow motion to improve supination deformity (common in C5-6 tetraplegia), biceps tendon can be redirected through the interosseous membrane then reattached to itself

Lumbrical plus deformity: paradoxical extension of the PIP joint during attempted flexion, caused by distal amputations, excessively long FDP tendon interposition grafts, excesseve FDP tendon lengthening procedures management of traumatic amputation of leg below knee with exposed tibia, inadequate soft tissue coverage: immediate coverage with filet-of-foot free flap major limb replantation, re-establish blood flow first if approaching 6hrs of warm ischemia (12 hrs cold ischemia) order of importance in 5 finger replants: thumb, long or ring, index last transposition of index to long finger best performed at metacarpal base where theres greater volume of cancellous bone, higher rate of union paresthesias of thumb after ORIF = acute carpal tunnel syndrome 25 yo steelworker with posttraumatic trapeziometacarpal arthritis of thumb, failed conservative management rx trapeziometacarpal arthrodesis Zone II flexor tendon injury: immediate, early active flexion results in greater total active motion closed reduction of dislocated CMC joint: axial traction, pronation, manual pressure over the metacarpal base Secretans disorder (peritendinous fibrosis): edema of dorsal hand and factitious lymphedema, assoc w/ minor work-related trauma brachial plexus injury at birth: function of deltoid and biceps at 2 months predictive of normal function o Disruption of preganglionic nerve root results in loss of motor conductivity but maintenance of sensory Hand fasciotomies: intrinsics can be released through 4 incisions o Interossei and adductor pollicis: 2 dorsal incisions over 2nd and 4th metacarpals o Hypothenar eminence: over ulnar fifth metacarpal o Thenar eminence: radial first metacarpal Treatment for rupture of FDP 5 wks after repair is exploration and repair Outcome for flexor tendon repair: 5 > 1,3,4 > 2 Treatment of neuroma in-continuity o Excision, preserve functioning fascicles o Sural nerve graft Only life-threatening conditions are contraindications for replantation Treatment for grade III ring avulsion (complete degloving) is completion amputation Split nail deformity involving sterile and germinal matrices requires full-thickness nail graft, usually from toe Coverage of tibial defects: o proximal 1/3 gastroc o middle 1/3 soleus o distal 1/3 free flap with brachial artery injury, anterior interosseous artery is susceptible to occlusion, deep muscle affected firt: FPL and FDP Stener lesion: o Occurs with ulnar collateral ligament tears in thumb (Gamekeepers thumb) o Palpable mass on ulnar aspect of MC head o Adductor aponeurosis interposed btwn ruptured ulnar collateral ligament and base of proximal phalanx o Sx: painful instability to radial stress of MCP joint

Anatomic structures encountered in repairing ulnar collateral ligament from superficial to deep o Sagital bands: stabilize EPL over MP joint o Adductor aponeurosis o Ulnar collateral ligament During ray amputation, the deep intermetacarpal ligaments are sutured to close the dead space treatment of acute sagital band injury is splinting in extension

Fractures, Dislocations Dorsal dislocation of PIPJ o reduction prevented by flexor tendons or volar plate, reduction requires partial division of A3 pulley o simple dorsal dislocation of MCP joint can be reduced by flexing wrist while applying pressure at base of proximal phalanx directed dorsally and volarly o unstable dorsal dislocations of PIPJ: volar plate arthroplasty

Volar dislocations irreducible secondary to central slip and lateral band tightening around condyle preventing reduction Dislocation of MPJ: o closed reduction prevented by lumbrical (radial), volar plate, FDP (ulnar) o to reduce, flex wrist and apply pressure distally and volarly to base of proximal phalanx Irreducible volar rotary dislocation of PIP joint occurs following partial rupture of the volar plate, collateral ligament , accessory collateral ligament; ipsilateral condyle of prox phalanx gets entrapped between central slip and lateral band; to close reduce traction and extension of middle phalanx; open repair involves repair of lateral band 80-95% of fractures of distal phalanx have associated nail bed lacerations o 60% of pts w/ subungual hematoma > 50% have nail bed lacerations Type IV mallet injury w/ > 30% of articular surface avulsion: close reduction, longitudinal pin fixation o Mallet finger untreated up to 12 wks can be treated conservatively w/ 6 wks splinting Salter-Harris classification o Type I: epiphysis o II: metaphysis and epiphysis o III: epiphysis and articular surface o IV: diaphysis, epiphysis and articular surface o V: epiphysis compressed Spiral fractures occur from torsional loads intra-articular fractures phalanges w/ severe comminution or instability best rxd w/ dynamic traction

Wrist

Scaphoid non-union: in fractures displaced > 1mm treated w/ cast immobilization o 55% non-union, 50% avascular necrosis; appropriate rx is reduction and compressive rigid fixation

Scaphoid-perilunate fracture dislocation o Fall on outstretched hand o AKA scaphoid-dorsal perlunate fracture-dislocation Rx of displaced (>1mm) scaphoid waist fracture: ORIF w/ compression screw fixation Rx of nondisplaced transverse scaphoid waist fracture: immobilization in thumb spica for 10-14 wks SLAC (scpholunate advanced collapse) rx with total wrist arthrodesis for arthritis affecting radioscaphoid and capitolunate articulations unstable type III dorsal fracture-dislocation treated w/ palmar plate advancement arthroplasty DISI is caused by tear of the scapholunate ligament Scaphoid fractures: proximal fx more likely to disrupt blood supply, high rate of avascular necrosis, ORIF Perilunate instability o Mayfield described 4 stages of perilunate instability starting at scapholunate interval, rotating clockwise to capitolunate, lunotriquetral, radiolunate joints o Mayfield I scapholunate interosseous ligmament (SLIL) injury o Mayfiled II capitolunate joint disruption o Mayfield III dorsal perilunate dislocation w/ lunotriquetral ligament disruption o Mayfield IV radiolunate dislocation w/ perilunate injury w/ volar dislocation of lunate from lunate fossa into carpal tunnel o Diagnosis on plain xray o Potential for neurovascular injury, compartment syndrome, acute carpal tunnel syndrome o Rx: ORIF and ligament repair SLAC wrist (scapholunate advanced collapse) o Most common cause of degenerative arthritis of wrist o Stages Radioscaphoid Radial midcarpal Ulnar midcarpal Pancarpal o Xray: radioscaphoid arthrosis and dorsiflexed intercalated segment instability deformity (DISI) o DISI: lunate slips into statically dorsiflexed position > 10 deg similarly, when lunate lies palmar to capitate but faces dorsally, collapse pattern is also consistent w/ dorsiflexion instability DISI deformity is also present when the scapholunate angle is greater than 70 deg o goals of surgery: decrease pain, optimize wrist function o scaphoid excision and 4 corner arthrodesis lunate, capitate, hamate, triquetrum treatment for pt w/ pseudogout (calcium pyrophosphate disease) and SLAC wrist and severe pain is total wrist arthrodesis

DISI: - lunate will tend to flex w/ loss of ulnar ligamentous support from the triquetrum; - lunate extends when there is loss of radial ligamentous stability; - DISI may arise as a result of: - scaphoid fx; - scapho-lunate dissociation; - perilunate dislocation (esp trans-scaphoid perilunate dislocation); - end result may be SLAC wrist; - Radiographic Analysis: - on lateral x-rays, when lunate slips into statically dorsiflexed position > 10 deg, condition is defned as DISI; - similarly, when lunate lies palmar to capitate but faces dorsally, collapse pattern is also consistent w/ dorsiflexion instability;

- DISI deformity is also present when the scapholunate angle is greater than 70 deg; - when diagnosising this condition, be sure that the lateral radiograph was taken w/ proper technique and that the wrist is not dorsiflexed VISI - by definition, consists of volar flexion of the lunate relative to the longitudinal axis of the radius and capitate, when the wrist rests in a neutral position; - lunate will tend to flex when there is loss of ulnar support from the triquetrum; - may result from disruption of radial carpal ligaments on ulnar side of wrist & is characterized by scapholunate angle < 30 deg; - volar flexion instability pattern is usually associated w/ triquetrolunate dissociation or triquetral-hamate instability; - the dorsal-radial-triquetral and triquetro-scaphoid ligaments have an increase space (increased "V") between them; - see: ligaments of the wrist Scapholunate advanced collapse Discussion: - scapholunate advanced collapse (SLAC) refers to a specific pattern of osteoarthritis and subluxation which results from untreated chronic scapholunate dissociation or from chronic scaphoid non-union; - degenerative changes occur most often in areas of abnormal loading; - radial-scaphoid joint is involved initially, followed by degeneration in the unstable lunatocapitate joint, as capitate subluxates dorsally on lunate; - Radiographs: - radioscaphoid joint is first to develop degenerative changes; - capitolunate & STT joints, follow in order w/ degenerative changes; - capitate migrates proximally into space created by scapholunate dissociation; - radiolunate joint is usually spared because of concentric articulation of lunate w/ in speroid lunate fossa of distal radius; - lunate: - w/ end stage SLAC midcarpal joint collapses under compression & lunate assuming an extended or dorsiflexed position (DISI deformity); - Treatment: - proximal row carpectomy: - advantages are that it is technically easy, and often allows better preservation of strength and motion, as compared to limited carpal arthrodesis; - patients can expect over 60% of normal ROM as compared to opposite wrist and over 90% of normal grip strength; - this compares to four corner fusion, in which patients can expect less than 50% ROM and about 75% grip strength; - relatively contra-indicated w/ capitolunate arthrosis; - wrist fusion: - limited carpal fusion: (LCF); - 4 corner fusion: - involves preservation of radiolunate joint and stabilization of the midcarpal row - scaphoid excision w/ arthrodesis of capitate-lunate-hamate-triquetrum - usually LCF is combined w/ scaphoid excision inorder to adress radioscaphoid arthrosis; - incomplete reduction of the dorsiflexed lunate may result in limitation of wrist extension; - may be indicated for wrists w/ more extensive intercarpal arthrosis; Scapholunate Dissociation - hyperextension injury to wrist assoc w/ ulnar deviation and midcarpal supination - injury to scapholunate ligament - lunate and triquetrum rotate into abnormal extension (DISI), supination and radial deviation

scaphoid abnormally flexes, ulnar deviates, pronates Sx: weak grip, limited motion, swelling, point tenderness over SL interval Maximal tenderness: flex wrist, palpate dorsum of capsule distal to Listers tubercle Watsons shift o Press on distal pole of scaphoid, deviate wrist ulnar to radial, in ulnar deviation scaphoid is extended, on radial deviation scaphoid flexes, pressure on tuberosity prevents flexion and if SL ligament si torn, proximal pole subluxes dorsally causing pain, when pressure released scaphoid self-reduces o Low specificity Xrays o o o Increased SL joint space: measured in middle of flat medial facet of scaphoid, > 5mm is diagnostic of SLD Scaphoid ring sign: scaphoid collapsed into flexion has foreshortened appearance in AP view, scaphoid tuberosity projects in coronal plane as radiodense circle over distal 2/3 of scaphoid Increased SL angle on lateral: scaphoid is more perpendicular to long axis of radius, angle > 45-60 deg Predynamic: pain at SL joint, + shift test, xray normal Dynamic Static Scapholunate Advanced Collapse (SLAC): long standing dz, extensive degeneration of radioscaphoid and/or lunocapitate articular cartilage

Staging o o o o

Treatment Acute - closed reduction and casting: not acceptable - closed reduction percutaneous pinning: k wires through radial styloid and scaphoid and lunate, between scaphoid and lunate; results depend on size of gap and duration of sx; immobilize 8-10 wks - ORIF, repair of ligaments o Assures subluxation is reduced o See and treat osteochondral damage o Direct repair of torn ligaments o Dorsal vs volar approach Subacute with reducible SL dissociation w/o arthrosis - subacute if joint is easily reducible and no cartilage wear - some advocate re-creation of SL interosseous linkage using remnants of interosseous ligament - Dorsal radioscaphoid capsulodesis o Blatt raised a proximally based 1 cm wide dorsal capsuloligamentous flap, reduced scaphoid and pinned w/ 0.045 K wire from scaphoid to lunate, flap inserted into dorsum of scaphoid o Post-op thumb spica x 2 months, k wire another month, motion at 3 mo o Variations - Palmar radioscapholunate capsular reinforcement o Create fibrous union between scaphoid and lunate o Not effective - Tenodesis o Tendon grafts to augment SL ligament repairs o Different techniques use ECRB or FCR to reconstruct SL ligament and augment triquetrum scaphoid ligament - Bone-ligament-bone grafts o Allografts, need more studies Chronic, irreducible SL dissociation w/o cartilage degeneration

irreducible defines chronic STT arthrodesis o Scaphoid, trapezium, trapezoid: Triscaphoid fusion o Realign proximal pole of scaphoid relative to scaphoid fossa o Articular cartilage removed, gaps filled w/ bone graft o Non-union rate 14% o Pain relief inconsistent o ROM and strength decreased o Pain from impingment on radial styloid, can do styloidectomy SL Arthrodesis o One of least reliable treatments o 50% non-union rate SC Arthrodesis o Similar effect as STT Scaphoid-lunate-capitate (SLC) arthrodesis o 50% reduction in wrist motion o Indicated for severe fixed instability w/o degenerative changes on proximal pole scaphoid and radius o 25% later require total wrist fusion from pain

Chronic, irreducible SLD w/ cartilage degeneration - longstanding SLD causes progressive deterioration of adjacent joints - results in SLAC wrist - RS joint then midcarpal joint starting w/ lunocapitate - Radiolunate typically spared - Soft tissue procedures and intercarpal arthrodesis contraindicated - Salvage procedures - Radius-scaphoid lunate arthrodesis o If arthritis confined to radiocarpal joint, midcarpal joint normal, arthrodesis of RS joint or RSL joint may help - Radial styloidectomy o Relieves pain caused by impingement between tip of radial styloid and malpositioned distal scaphoid o Care not to detach volar insertion of radiocarpal ligaments o Usually adjunct procedure - SLAC wrist operation o Combination scaphoid excision, capitate lunate-triquetrum-hamate fusion o Good articular cartilage at radiolunate level o 12% dorsal impingement between dorsal edge of radius and capitate o Need to fully correct DISI deformity - Proximal row carpectomy o Controversial salvage o Creates a single ball-socket joint w/ nonmatching articular surfaces o Need good articular cartilage proximal pole capitate and lunate fossa of radius - total wrist arthroplasty o not for young - total wrist arthrodesis o pain relief in 85%, 65% return to work Authors preferred methods of treatment 1. acute: open reduction, ligament repair, dorsal capsulodesis 2. subacute: same as acute, as long as malialignment easily correctable and good ligmanets, if no good ligaments, Brunellis tendon reinforcement technique 3. malalignment is not reducible, no cartilage damage: localized SC fusion or SLC fusion 4. local arthritic changes at RS but not midcarpal bones: radioscapholunate fusion + excision of distal third of scaphoid 5. advanced SLAC wrist: scaphoidectomy + capitate-hamate-triquetrum-lunate (4 corner) fusion

6.

global post-traumatic arthrosis: total wrist fusion