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Plastic
Surgery
Copyright
Contents
Video Contents
Lecture Video Contents
Preface to the Fifth Edition
List of Editors
List of Contributors
Acknowledgments
Dedication
Plastic surgery and innovation in medicine
1
Plastic surgery and innovation in medicine
Introduction
Adaptation and change
Innovation and research
Major innovations
Making innovation safe
Collaboration and teamwork
Documentation, data-gathering, and regulation
Conclusion
References
History of reconstructive and aesthetic surgery
2
History of reconstructive and aesthetic surgery
Historical definition of plastic surgery
Origin of plastic surgery
The distant past – the wound as a problem
In Ancient Egypt
In Mesopotamia
In India
In Greece
In Rome
Plastic surgery after the decline of the Roman Empire
Byzantine surgery
The Middle Ages
Arabian surgery
The rise of the universities
The invention of printing
The Renaissance
Renaissance surgery
The decline of plastic surgery
The rebirth of plastic surgery
The nineteenth century
The golden age of plastic surgery
The twentieth century
The origin of modern plastic surgery
The training programs
The birth of the scientific societies
The scientific journals
Postwar plastic surgery
Aesthetic surgery
The origin
The development
The problem of the beauty doctors
Postwar aesthetic surgery
References
Further reading
Applying psychology to routine plastic surgery practice
3
Applying psychology to routine plastic surgery practice
Introduction
What motivates people to seek appearance-altering surgery?
The prevalence of appearance dissatisfaction in the general population
What are the characteristics of people who seek cosmetic interventions?
Visible differences (disfigurement) and reconstructive surgery
Does cosmetic surgery meet patients’ needs? The psychological benefits and limitations of cosmetic surgery
Who is psychologically vulnerable – does vulnerability lead to poorer outcomes?
Mental health problems
How can I manage my patients more effectively?
Communicating effectively
Screening and assessment
Understanding motivation and modifying expectations of outcome
Facilitating the understanding of risk
Promoting patient involvement in treatment decision-making
Incorporating psychological care into routine practice in cosmetic surgery
Managing mental health issues
Summary
References
The role of ethics in plastic surgery and medico-legal issues in plastic surgery
4
The role of ethics in plastic surgery and medico-legal issues in plastic surgery
Introduction
History of ethics and plastic surgery
Core ethical principles and plastic surgery
Patient communication, education, informed consent, and disclosure
Conflict of interest
Concurrent and overlapping surgery
Medical errors
Expert witness testimony
Social media and advertising
Conclusions
References
Business principles for plastic surgeons
5
Business principles for plastic surgeons
Introduction
Strategy
Accounting
Income statement
Balance sheet
Summary of cash flows
Financial ratios
Profitability ratios
Leverage ratios
Liquidity ratios
Efficiency ratios
Finance
Time value of money
Opportunity cost
Net present value (NPV) and discounted cash flows (DCF)
Return on investment (ROI)
Economics
Marketing
Operations
Innovation
Entrepreneurship
Sustainable enterprise
Human resource management
Legal and regulatory considerations
Sarbanes–Oxley Act, 2002
American Recovery and Reinvestment Act, 2009
Patient Protection and Affordable Care Act, 2010
Dodd–Frank Wall Street Reform and Consumer Protection Act, 2010
The Coronavirus Aid, Relief, and Economic Security Act, 2020
Negotiation
Ethics
Leadership
Acknowledgments
References
Additional Reading
Value-based healthcare
6
Value-based healthcare
Introduction
Why value-based healthcare matters in plastic surgery
Defining value within plastic surgery
The numerator: Clinical outcomes and patient-reported outcomes measures
The denominator: Cost
Practical implementation of value-based plastic surgery
Cosmetic/aesthetic surgery – translational lessons for value-based care?
Tools for value-based care in plastic surgery
Shared decision-making
Cost-effectiveness analysis
Implementation science
Future directions
Conclusions
References
Digital photography in plastic surgery
7
Digital photography in plastic surgery
Purpose
Standards in capturing images
Digital image characteristics
Background
White balance
Lens aperture and shutter speed
Focal length and distortion
Composition and positioning
Full face
Eyes
Glabella
Nose
Lips, nasolabial folds, and mentum
Dental occlusal views
Ears
Chest and breast
Lower trunk, abdomen, and buttocks
Lower extremity
Hands and feet
Specialty views
In the hospital and operating room
Archiving and image management
Cameras
Storage
File formats
Image attributes, metadata, and retrieval
Digital image processing
Measurement and analysis
Planning and simulation
New frontiers
Three-dimensional surface imaging
Video
Digital image manipulation
Presentations
References
Pre- and intra-operative imaging for plastic surgery
8
Pre- and intra-operative imaging for plastic surgery
Introduction
Traditional imaging techniques
External photography
Standard photography
Three-dimensional (3D) photography
Cross-sectional imaging
Diagnostic ultrasound (US)
Computed tomography angiography (CTA)
Magnetic resonance imaging (MRI)
Image-guided 3D surgical planning
Virtual surgical planning (VSP)
3D printing
Novel intra-operative imaging techniques
Perfusion-guided imaging
Indocyanine green (ICG)
Laser Doppler
Dynamic infrared thermography
Surgical navigation
Mixed reality
Eye tracking
New frontiers in surgical training
Conclusion
References
Patient safety in plastic surgery
9
Patient safety in plastic surgery
Introduction
Preoperative
ASA classification
Preoperative risk stratification and optimization
Risk stratification and risk modification for venous thromboembolism
Perioperative medication cessation
Intra-operative
Intra-operative checklist use
Intra-operative malignant hyperthermia
Intra-operative VTE risk reduction
Prevention of hypothermia
Operating room fire prevention
Patient safety in teaching hospitals
Patient safety in ambulatory surgery centers and office-based settings
Intra-operative procedure-specific concerns
Procedures that tighten the abdominal wall
Liposuction and local anesthesia toxicity
Gluteal fat grafting
Postoperative
Postoperative VTE risk reduction
Anticoagulation in postoperative patients
Opioid management
Conclusions
References
Anesthesia and pain management in plastic surgery
10
Anesthesia and pain management in plastic surgery
Introduction
Clinical consequences of inadequate pain relief
Acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective inhibitors
Acetaminophen
Nonsteroidal anti-inflammatory drugs
COX-2 receptor inhibitors
NMDA-receptor antagonists and gabapentinoids
Ketamine
Gabapentinoids
Opioids
Local anesthetics
Minimizing pain with injection of local anesthesia
Liposomal delivery of local anesthetics
Local anesthetic infiltration into operative sites (wound infiltration)
Tumescent analgesia in plastic surgery
Fluid composition
Epinephrine in tumescent analgesia
Complications of tumescent anesthesia
Peripheral regional and neuraxial analgesia in plastic surgery
Pectoral 1 and 2 blocks
Erector spinae block
Transversus abdominis plane block
Upper and lower extremity peripheral nerve blocks
Paravertebral block
Neuraxial analgesia
Spinal and epidural anesthesia
Summary
References
Evidence-based medicine and health services research in plastic surgery
11
Evidence-based medicine and health services research in plastic surgery
The best evidence – where do we find it?
Evaluating existing literature
Literature search strategies
PubMed
Clinical Queries
PICO(T)
Systematic reviews
Meta-analysis
Network meta-analysis
Study design and levels of evidence
Experimental studies: Randomized controlled trials
Challenges of RCTs for comparing surgical interventions and possible solutions
Possible solution: Expertise-based randomized controlled trials
Possible solution: Multicenter trials
Limitations of randomized controlled trials: investigating harm
Observational studies
Cohort studies
Case–control studies
Case series and case reports
Large-database analysis
Population-based research
Effectiveness versus efficacy
The importance of power and understanding the P-value
Data sources
Clinical registries
Administrative claims data
Using large databases for research
Large cohort studies
Administrative data
Small-area variation
Volume–outcome analysis
Epidemiology
Examples of large-database analyses in plastic surgery
Patient-reported outcomes research
Utilities and preference-based measures
Key concepts
Comparative effectiveness research
Definition
National research priority
Types of economic studies
Complexities
Whose perspective to take?
Study design
Limitations
Summary
The preconditions to credible clinical research in plastic surgery
Future trends
Knowledge translation (KT)
A model for understanding KT
Barriers to uptake
Learning collaboratives
Role of electronic health records/integrating data collection into flow of usual care versus research
Possible solutions: generic
Possible solutions: plastic surgery and PROMs
What do we do with the outcomes?
Performance measures
Public reporting and pay-for-performance (P4P)
Decision aids for patients
Conclusions
Acknowledgment
References
Patient-reported outcomes in plastic surgery
12
Patient-reported outcomes in plastic surgery
Introduction
Early PROMs in plastic surgery
Types of PROMs
Methodology involved in modern PROM development
Step 1: Hypothesize conceptual framework
Step 2: Adjust conceptual framework, draft PROM and cognitive debriefing
Step 3: Confirm conceptual framework and assess other measurement properties
Step 4: Finalize the instrument
Computerized adaptive testing (CAT)
Characteristics to consider when selecting a PROM
Validity
Reliability
Responsiveness
Minimal important difference
Feasibility and burden
Future directions for PROMs in plastic surgery
Summary
References
Health services research in plastic surgery
13
Health services research in plastic surgery
What is health services research?
Plastic surgeons and HSR
Eliminating inequities – necessary considerations for impactful work
Considering structural root causes
Taking action toward equitable research and outcomes
Health policy research
Why does health policy matter to surgeons?
How to engage with policy?
Causal inference: limits and opportunities with observational data
Measuring quality
The future of assessment and technical improvement
Assessing patient-reported outcomes
Comparative effectiveness
Collaborative quality improvement
Implementation science: how to change practice
Qualitative research methods – an underused approach
Collecting and working with qualitative data
Conclusions
References
Principles of cancer management
14
Principles of cancer management
Background
Cancer presentation and initial evaluation
Cancer diagnosis and treatment planning
Critical mass
Tumor margins
Classification and staging
Treatment planning
Localized treatments
Surgery
Radiation
Photodynamic therapy
Systemic treatments
Chemotherapy
Targeted therapies
Immunotherapy
Cancer management: the plastic surgeon perspective
Conclusions
References
Wound healing
15
Wound healing
Introduction
The wound healing process
Normal wound healing
Hemostasis
Inflammation
Proliferation
Maturation, or remodeling
Abnormal wound healing
Chronic wounds
Fibrosis and exuberant scar formation
Factors affecting wound healing
Age
Obesity
Diabetes
Medications
Malnutrition
Oxygen
Infection
Wound types and treatments
Acute wounds
Lacerations and avulsion injuries
Burn injuries
Superficial burn injury
Deep burn injuries
Chronic wounds
Diabetic foot ulcers
Ischemic ulcers and pressure sores
Venous ulcers
Exuberant wound healing
Keloids
Hypertrophic scars
Wound dressings
Moist wound healing
Moist wound dressings
Alginate dressings
Film dressings
Foam dressings
Hydrocolloid dressings
Hydrogel dressings
Negative pressure wound therapy
Topical oxygen therapy
Skin tissue engineering
Approaches to skin regeneration
Cell therapy
Growth factor therapy
Dermal substitutes
Gene therapy
Wound imaging and assessment techniques
Wound healing research
In vitro research
Animal research
Murine and rodent wound models
Rabbit wound models
Porcine models
Clinical research
Future directions and opportunities
References
Scar prevention, treatment, and revision
16
Scar prevention, treatment, and revision
Personal and social significance of scars
History and physical examination
Assessing scars
Scar biology
Scar prevention: skin regeneration after repair
Conditions of excessive scarring
Hypertrophic scar
Keloid
Prevention
Surgical technique
Patient-specific factors
Wound infections and foreign-body reactions
Adjunct therapy
Treatment
Treatment of hypertrophic scars
Treatment of keloid scars
Preventative management for hypertrophic and keloids scarring
Scar revision
Introduction
Indications
Timing
Planning
Scar release
Principles of tissue rearrangement
Scar revision techniques
Wound dressings and postoperative care
Mechanical shield
References
Skin grafting
17
Skin grafting
Introduction
The need for skin
History of the graft technique
Anatomy and physiology of skin
The laminar integument
The skin
Epidermis
Dermal–epidermal junction
Dermis
Dermal–hypodermal junction
Hypodermis
Structures of the skin
The cutaneous niche
Vascular supply of the skin
Lymphatic drainage
Neuronal supply of the skin
Cutaneous appendages and the adnexal niche
Physiology and functions of the skin
Cutaneous homeostasis
The skin as a barrier
Restoration of barrier function after injury
Metabolic and regulatory functions of the skin
UV protection, melanocytes, and pigmentation
Immunology of the skin and the cutaneous microbiome
The skin graft
Clinical application
Split-thickness skin grafts
Grafting technique
Meshed skin grafts
Full-thickness skin grafts
Composite grafts
Skin fixation and dressings
Recipient site considerations
Wound bed preparation
Functional and aesthetic considerations
Donor site considerations
Management of complications
Hematoma/seroma
Infection
Instability
Other factors
Physiology of skin graft survival
Skin appendages and other structures
Beyond the graft
Adjunctive therapies to autografting
Graft expansion
Soft-tissue augmentation
Long-term graft storage
Non-autologous alternatives and adjuncts
Acellular extracellular matrices
Allogeneic and nonhuman grafting of whole tissues
Cell-seeded constructs
References
Tissue engineering
18
Tissue engineering
Introduction
Plastic surgery principles in tissue engineering and the first 40 years
The first evolution of plastic surgery – random pattern and pedicle flaps and the culture of better solutions
The second evolution of plastic surgery – microsurgery and the precedent for better solutions
The third evolution of plastic surgery: tissue engineering, the answer beyond surgery
The fall of tissue engineering Mark-I
Issues that led to the collapse of the early tissue engineering sector
Tissue engineering Mark-II – focusing on the old domains and new paradigms
Modern tissue engineering – the TERM for progress
Cell biology and cell signaling – a complex interplay of individual fields of expertise
Biomaterials biology
Case studies of tissue engineering in plastic surgery
Skin tissue engineering
Engineering therapeutic delivery in skin
Antifibrotic therapies
Engineering lymphatics in skin
Scaffold-based approaches to lymphatic engineering
Macrovascular lymphatic scaffolds
Microvascular lymphatic scaffolds
Interstitial flow-based lymphatic engineering models
Secondary lymphoid scaffolds
Non-scaffold approaches
Conclusion and future perspectives
References
Repair, grafting, and engineering of cartilage
19
Repair, grafting, and engineering of cartilage
Introduction
Autologous cartilage grafts and applications6
Auricular cartilage graft
Nasal cartilage graft
Rib cartilage graft
Autologous perichondrial graft
Cartilage engineering
Introduction and basic principle
Engineering of auricular cartilage
Engineered cartilage for rhinoplasty and facial contouring
Engineered cartilage for joint cartilage repair and reconstruction
Clinical translation of engineered human ear cartilage
Future directions
Stem cell-based cartilage engineering
In vitro engineering of cartilage with enhanced mechanical strength
Design and precise control of engineered cartilage 3D structure
References
Repair and grafting of bone
20
Repair and grafting of bone
Microanatomy and histochemistry
Cortical versus cancellous bone
The chemical composition of bone
Inorganic phase
Organic phase
The cellular composition of bone
Osteoblasts
Histology and function
Regulation of osteoblast differentiation
Major signaling pathways
Transcriptional regulation
Osteocytes
Histology
Osteocyte function
Osteoclasts
Histology and function
Osteoclast differentiation
Extracellular matrix
Principles of bone homeostasis and turnover
Wolff's law and mechanotransduction
Bone regeneration: the role of the stem cell
Molecular mechanisms of bone regeneration
Bone morphogenetic protein
Bone morphogenetic protein function
Transforming growth factor-β
Fibroblast growth factor
Platelet-derived growth factor
Healing of fractures
Primary bone repair
Secondary (callus) bone repair
Variables influencing bone repair
Blood supply
Fracture fixation
Age
Bone remodeling
Osteoinduction
Osteoconduction
Osseointegration
Distraction osteogenesis
Histology
Variables affecting osteogenesis
Patient factors
Age
Blood supply
Radiation/chemotherapy
Clinical application of bone transfers
Indication for bone transfers
Bone graft healing and graft survival
Cancellous versus cortical grafts
Clinical considerations
Techniques of harvest: autologous bone grafts
Ilium
Tibia and fibula
Greater trochanter and olecranon
Rib
Calvarium
Vascularized bone flaps
Vascularized iliac transfer
Vascularized fibula
Vascularized scapula
Vascularized rib
Vascularized calvarium
Principles of bone transfer
Allogeneic bone grafts
Processing and preservation
Risk of disease transmission
Immunogenicity
Incorporation of allograft bone
Formulations of allogeneic bone grafts
Xenogeneic bone grafts
Bone substitutes
Cement pastes
Calcium phosphates
BoneSource
Norian SRS/CRS
Osteoactive materials
Prefabricated polymers
Methylmethacrylate
Medpor
Experimental scaffolds
References
Repair and grafting of peripheral nerve
21
Repair and grafting of peripheral nerve
Introduction
Pathophysiology of nerve injury
Classification of nerve injury
Mechanism of nerve injury
Penetrating injuries
Crush injuries
Stretch and avulsion injuries
Evaluation of nerve injuries
History and physical examination
Electrodiagnostic evaluation
Imaging
Patient selection
Treatment
Nerve repair
Timing of repair
Tension
Type of repair
Intraoperative nerve stimulation
Bridging the nerve gap
Autologous nerve grafting
Nerve allografts
Nerve conduits
Nerve transfers
Bioengineering and adjunctive therapies to improve nerve regeneration
Postoperative care
Prognosis and outcomes
Secondary procedures
Summary
Acknowledgment
References
Repair and grafting fat and adipose tissue
22
Repair and grafting fat and adipose tissue
Introduction
Historical perspective
Basic science
Adipose tissue: structure and physiology
Biology of ASCs
Fat harvesting, preparation, and grafting techniques
Safety concerns
Diagnosis/patient presentation
Patient selection
Treatment/surgical technique
Harvesting
Refinement
Placement
Postoperative care
Outcomes, prognosis, and complications
Secondary procedures
References
Vascular territories
23
Vascular territories
Introduction
Historical perspective
Vascular anatomical research
Angiosome
Arterial territories
Venous drainage
Neurovascular territories
Neurovascular anatomy of muscles of the body
Comparative anatomy
The angiosome concept
The anatomical and clinical territory of a cutaneous perforator
Vascular territories of the body
Vascular territories of the forearm
Forearm skin
Muscles
Forearm bones
Clinical implications
Donor site morbidity
Free-flap donor sites
Vascular territories of the lower leg
Lower leg skin
Lower leg muscles
Anterior leg muscles
Lateral leg muscles
Posterior leg muscles
Leg skin vascular supply
Connective tissue framework
Compartment syndromes
Flap donor sites
Vascular anastomoses around the knee
Vascular territories of the head and neck
Head and neck skin and superficial musculoaponeurotic system
Head and neck muscles
Muscles of facial expression
Ocular muscles
Muscles of mastication
Posterior neck muscles
Lateral neck muscles
Anterior neck muscles
Aerodigestive system
Internal nose
Tongue and floor of mouth
Palate, pharynx, larynx, esophagus, and trachea
Glands
Anatomic concepts related to flap design
Vessels follow the connective tissue framework of the body
Arteries radiate from fixed to mobile areas and veins converge from mobile to fixed areas
Vessels “hitchhike” with nerves
Vessel growth and orientation are products of tissue growth and differentiation
Vessels interconnect to form a continuous three-dimensional network of vascular arcades
Arteries
Veins
Vessels obey the law of equilibrium
Vessels have a relatively constant destination but may have a variable origin
Venous networks consist of linked valvular and avalvular channels that allow equilibrium of flow and pressure
Directional veins
Oscillating avalvular veins
Muscles are prime movers of venous return
Superficial veins follow nerves and deep veins follow arteries
Applications of the angiosome concept
Preoperative assessment of the cutaneous vascular supply
Flap design
Dopplers
Color duplex Doppler
CT angiography
Axes of skin flaps
Distally based skin flaps
Skin flap dimensions
Fasciocutaneous flaps
Musculocutaneous flaps
Perforator flaps
The delay phenomenon
Composite flaps
Angiosome concept and flap design
References
Flap physiology, classification, and applications
24
Flap physiology, classification, and applications
History
Classification of flaps
Flaps based on the constituents
Muscle and musculocutaneous flaps
Fascia and fasciocutaneous flaps
Perforator flap (skin with fat and with or without fascia)
Visceral flaps
Bone flap (vascularized bone, osseous–periosteal flap)
Nerve flap
Lymph node flap
Flaps based on construction (flow)
Retrograde-flow flaps
Turbocharged and supercharged flap
Venous flaps (arterialized venous flap)
Flaps based on conditioning
Delay
Tissue expansion
Prelaminated and prefabricated flaps
Sensory flap
Functional muscle flaps
Flaps based on conformation
Flap applications
The reconstructive elevator
The guide for reconstruction using flaps
Preoperative planning
Intraoperative techniques
Postoperative management
Flap physiology
The no-reflow phenomenon
Selection of specific flaps
Muscle and musculocutaneous flaps
Fascia, fasciocutaneous, and perforator flaps
Perforator flap (free-style)
Regional application of flaps
Head and neck reconstruction
Breast reconstruction
Mediastinum
Chest wall and pulmonary cavity
Abdominal wall
Groin and perineum
Lower extremity
Foot
Posterior trunk
Pressure wounds
Microsurgical application of flaps
Free perforator flaps
Anterolateral thigh (ALT)
Deep inferior epigastic artery perforator (DIEAP) flap
Thoracodorsal artery perforator (TDAP) flap
Complications
References
Principles and techniques of microvascular surgery
25
Principles and techniques of microvascular surgery
Introduction
Historical perspective
Tools
Surgical microscopes
Loupes
Types
Choosing loupes
Microsurgical instruments
Types
Scissors
Needle holders
Forceps
Vascular clamps
Bipolar coagulator
Irrigation and suction
Microsutures
Anastomotic devices
Other non-suture methods
General principles of microvascular surgery
The working environment
Training
Planning and positioning
Securing the flap or flap inset
Selection and dissection of recipient vessels
Preparation of vessels
Anastomoses sequence
Microvascular anastomosis techniques
Suturing techniques
End-to-end anastomosis
End-to-side
Use of the coupler
Difficult, less commonly encountered microvascular anastomosis
Anastomosis between size-discrepant vessels
Vertically oriented anastomosis
Atherosclerosis and loose intima
Microvascular grafts
Testing patency
General aspects of free flap surgery
Advantages and disadvantages
Preoperative evaluation
Patient factors
Recipients and donor site evaluation
Choice of flap
Timing
Microvascular anesthesia
Special techniques and flap modifications
Endoscopic harvest
Robot-assisted free flap surgery
Perforator flaps, free-style flaps, and supramicrosurgery
Combined flaps
Thinned flaps
Prefabricated/prelaminated flaps
Postoperative management, complications, and outcomes
Monitoring
Telemonitoring
Buried flaps
Flap outcomes
Causes of a failing flap
Anastomotic failure
Vasospasm
Thrombogenesis
Ischemic tolerance, ischaemia–reperfusion injury, and no-reflow phenomenon
Donor site complications – dependent again on flap choice
Management of failed flaps
The future of microsurgery
References
Tissue expansion and implants
26
Tissue expansion and implants
Introduction
Historical perspective
Tissue expanders
Breast implants
Basic science of tissue expansion
Cellular and molecular basis for tissue expansion/mechanotransduction
Vascularity of expanded tissue
Patient and tissue expander/implant selection
Tissue expanders and implant types
Tissue expanders
Tissue expander types with different port systems
Breast implants
Surface of breast implants
Filler material of breast implants
Shape of breast implants
Size of breast implants
Profile types of breast implants
Diagnosis/preoperative planning/implant selection
Tissue expansion
Breast implants
Treatment and surgical technique
Tissue expanders in head and neck surgery
Breast expanders
Breast implants
Postoperative care
Tissue expansion
Breast implants
Complications
Hematoma and seroma
Infection
Capsular fibrosis
Expander/implant malposition
Expander/implant rupture, deflation, and failure
Exposure of expander/implant
Flap ischemia and skin necrosis
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
Breast implant illness (BII)
References
Principles of radiation therapy
27
Principles of radiation therapy
Historical perspective
Introduction
Radiation technology
Cobalt radiation therapy
Linear accelerators (linacs)
Particle therapy
Electrons
Proton beam therapy
Neutron therapy
Carbon ion therapy
FLASH therapy
Brachytherapy
Physics
Radiation therapy delivery techniques
Three-dimensional conformal radiation therapy
Intensity-modulated radiation therapy (IMRT)
Stereotactic body radiation therapy (SBRT)
Intraoperative radiation therapy (IORT)
Radiobiology
Applications
Radiation treatment-planning and process
Clinical applications
Units of radiation
Treatment intention, fractionation, and dosing
Patient selection
Breast cancer
Breast conservation therapy
Indications for postmastectomy radiation (PMRT)
Radiation of the nodal draining areas
RT indications, dose, and techniques
Breast: Spotlight on upfront multidisciplinary evaluation topics
Head and neck cancer
Head and neck: Spotlight on upfront multidisciplinary evaluation topics
Sarcoma
RT indications, dose, and techniques
Sarcoma: Spotlight on upfront multidisciplinary evaluation topics
Skin cancers
RT indications, dose, and techniques
Skin cancers: Spotlight on upfront multidisciplinary evaluation topics
Pediatrics
RT indications, dose, and techniques
Pediatrics: Spotlight on upfront multidisciplinary evaluation topics
Benign disorders
Specific toxicities and complications
Bony injury
Bone growth in children
Cardiovascular disease
Lymphedema
Brachial plexopathy
Radiation-induced malignancies
Exposure to radiation
Conclusion and future trends
References
Lymphedema pathophysiology and basic science
28
Lymphedema: pathophysiology and basic science
Introduction
Anatomy and physiology
Lymphatic circulation
Lymph nodes
Etiology of lymphedema
Primary lymphedema
Secondary lymphedema
Pathophysiology of lymphedema
Lymphatic vascular defects in secondary lymphedema
Regulation of fibrosis
Regulation of adipose deposition
Epidermal changes
Risk factors of lymphedema
Obesity
Radiation
Infection
Genetics
Clinical presentation, evaluation, and diagnosis
Signs and symptoms of lymphedema
Differential diagnosis
Diagnostic measurements
Other diagnostic tools
Radiologic diagnosis of lymphedema
Near-infrared (NIR) lymphography with ICG dye
Patient-reported outcomes
Lymphedema classification
Summary
References
Benign and malignant nonmelanocytic tumors of the skin and soft tissue
29
Benign and malignant nonmelanocytic tumors of the skin and soft tissue
Introduction
Diagnosis
Inspection and palpation
Dermoscopy
Ultrasound and Doppler imaging
X-ray, CT, MRI, angiography, scintigraphy, and positron emission tomography (PET)
Pathologic diagnosis
The TNM clinical classification system and the pTNM pathologic classification system
Clinical staging
Treatment
Wide excision
Lymph node dissection
Axillary lymph node dissection
Inguinal lymph node dissection
Reconstructive surgery
Radiation therapy
Chemotherapy
Laser therapy
Others (including immunotherapy, cryotherapy, electrocoagulation therapy, and sclerotherapy)
Benign cutaneous and soft-tissue tumors
Benign epithelial-origin tumors
Epidermal nevus (e.g., verrucous epidermal nevus and linear epidermal nevus)
Seborrheic keratosis (also known as senile wart)
Keratoacanthoma
Epidermoid cyst (also known as epidermal cyst and atheroma)
Milia
Dermoid cyst
Others
Benign appendage-origin tumors
Nevus sebaceous
Pilomatricoma (also known as calcifying epithelioma and pilomatrixoma)
Trichilemmal cyst
Syringoma
Apocrine cystadenoma (also known as apocrine cysthidroma)
Chondroid syringoma (also known as cutaneous mixed tumor)
Others
Benign neural crest-origin tumors
Pigment cell nevus (also known as pigmented nevus and nevus cell nevus)
Lentigo simplex
Acquired pigment cell nevus
Congenital pigment cell nevus
Dysplastic nevus (also known as Clark’s nevus and atypical mole)
Juvenile melanoma (also known as Spitz nevus)
Nevus spilus (also known as café-au-lait spot)
Becker’s melanosis (also known as Becker’s pigmented hairy nevus)
Nevus of Ota (also known as nevus fuscoceruleus ophthalmomaxillaris and oculodermal melanocytosis)
Nevus of Ito
Mongolian spot (also known as congenital dermal melanocytosis)
Blue nevus
Neuroma
Schwannoma (also known as neurilemmoma)
Neurofibroma
Others
Benign mesenchymal-origin tumors
Dermatofibroma (also known as fibrous histiocytoma)
Xanthoma
Juvenile xanthogranuloma
Soft fibroma
Keloid and hypertrophic scars
Lipoma
Leiomyoma
Rhabdomyoma
Osteochondrogenic tumors
Accessory auricle (also known as nevus cartilagines)
Granuloma
Glomus tumor
Capillary malformation
Hemangioma simplex
Strawberry hemangioma
Venous malformation
Arteriovenous fistula and arteriovenous malformation (AVM)
Lymphatic malformation
Others
Malignant cutaneous and soft-tissue tumors
Malignant epithelial-origin tumors
Actinic keratosis
Bowen’s disease
Squamous cell carcinoma
Basal cell carcinoma
Malignant appendage-origin tumors
Sebaceous carcinoma
Trichilemmal carcinoma
Sweat gland carcinoma
Extramammary Paget’s disease
Merkel cell carcinoma
Malignant mesenchymal-origin tumors
Dermatofibrosarcoma protuberans (DFSP)
Pleomorphic undifferentiated sarcoma (PUS)
Liposarcoma
Leiomyosarcoma
Rhabdomyosarcoma
Osteosarcoma
Chondrosarcoma
Angiosarcoma
Kaposi’s sarcoma
Others
References
Melanoma
30
Melanoma
Introduction
Clinical evaluation – dermoscopy and confocal
Benign melanocytic lesions
Melanocytic nevi
Congenital nevi
Acquired naevi
Predisposing conditions
Melanoma
In situ melanoma
Superficial spreading melanoma
Nodular melanoma
Lentigo maligna melanoma
Desmoplastic melanoma
Acral/subungual
Staging
Tumor category
Regional nodal category
Distant metastasis category
Stage
Other histopathological features
Clark’s level
Neurotropism
Lymphovascular invasion
Tumor infiltrating lymphocytes (TILs)
Follow-up and imaging
Surgical considerations and management
Biopsy of a clinically suspicious melanocytic lesion
Wide local excision of primary melanoma
Wide excision of melanoma in situ
Sentinel lymph node biopsy
Management of sentinel node metastases
Management of clinically detected nodal metastases
Lymph node dissection (lymphadenectomy)
Neck dissection
Axillary dissection
Iliofemoral dissection
Distant metastases
Systemic therapy for melanoma
Immune checkpoint inhibitors
Targeted therapy
Adjuvant treatment
Adverse effects of systemic therapy
ICI
Targeted therapy
Radiotherapy
References
Implants and biomaterials
31
Implants and biomaterials
Historical perspective
Metals
Stainless steel
Cobalt–chromium
Titanium
Gold
Platinum
Polymers
Silicone
Silicone shell texturing
Polytetrafluoroethylene
Polyester
Polyprolene
Polyethylene
Biodegradable polymers
Polymer coatings
Ceramics
Adhesives and glues
Fibrin tissue adhesives
Platelet gels
Cyanoacrylate
Integra
Skin substitutes
Epicel (cultured epidermal autografts)
Dermagraft
Apligraf
Bioprosthetic mesh
Small intestinal submucosa
Human acellular dermal matrix
Porcine acellular dermal matrix
Other bioprosthetic mesh products
Amniotic/placental-based materials
Addressing the foreign body response
Future materials
References
Transplantation in plastic surgery
32
Transplantation in plastic surgery
Introduction
History of transplantation in plastic surgery
Transplant immunology
VCA program requirements
Selection of patients and donors
Patient selection
Donor selection
Surgical approach
Surgical preparations and graft procurement
Facial transplantation
Upper extremity transplantation
Postoperative care
Immunosuppression regimen
Clinical monitoring
Complications
Allograft rejection
Immunosuppression-related complications
Surgical complications/revision
Outcomes
Future of VCA
References
Technology innovation in plastic surgery a practical guide for the surgeon innovator
33
Technology innovation in plastic surgery: a practical guide for the surgeon innovator
Introduction
The idea
Determining the value
Funding
Intellectual property
Institutional technology transfer
FDA regulatory approval process
AI/ML device regulatory approval process
Starting clinical trials in plastic surgery
Innovating for global health and low- and middle-income countries
Conflict of interest
Innovations in plastic surgery
Negative pressure wound therapy
Acellular dermal matrix
Noninvasive body contouring
References
Robotics in plastic surgery
34
Robotics in plastic surgery
Introduction
Robotics in plastic surgery
Transoral robotic reconstructive surgery (TORRS)
Robotic microsurgery
Robotic flap harvest
Robotic harvest of the latissimus dorsi muscle flap
Robotic harvest of the rectus abdominis dorsi muscle flap
Robotic harvest of the deep inferior epigastric perforator flap (RoboDIEP)
Limitations of robotic surgery
Cost
Robotic training in plastic surgery
New frontiers in robotic plastic surgery
Conclusion
References
Digital technology in plastic surgery
35
Digital technology in plastic surgery
Introduction
Digital technology before the first consultation
Information on procedures
Choosing a surgeon
After selection
Digital technology during the office visit
Medical records and practice management
Choosing an EHR
Certification
Server on-site or off-site or subscription model (SaaS – Software as a Service)
Stability in the market
Features and functionality
Support and implementation
Contracting considerations
Using the EHR
Intake and entry of information via patient portals and onsite
Data entry at the time of the patient consultation
Alerts
Document and forms management
Integrated systems
Upfront investment of time – know your EHR
Photo system
Practice management
Billing
Reports
Theft prevention
Customer relation management
Security and safety
Onsite patient education
Digital educational materials
Digital simulation
On-site clinical information and decision-making
Perioperative digital technology
Preoperative workup
Assessing photographs in preoperative planning
Digital simulation in preoperative and intraoperative planning
Preoperative quotes and informed consent
Preoperative labs and studies
Automated preoperative workflows
Preoperative risk assessments and tools
Preoperative modeling
Day of operation
Preoperative holding digital technology
Intraoperative monitoring
Intraoperative communication and collaboration
Intraoperative tools for surgical decision-making
Postoperative digital technologies
Digital technology between patient visits (including long-term follow-up)
Direct patient communication
Patient monitoring with wearables and accessories
Patient community engagement online
Digital technology in plastic surgery education and training
Digital technology for the advancement of plastic surgery (research and clinical outcomes and advocacy)
References
Aesthetic improvement through noninvasive technologies
36
Aesthetic improvement through noninvasive technologies
Introduction
Cryolipolysis
Mechanism of action
Efficacy
Safety
Magnetic resonance contouring
Mechanism of action
Efficacy
Safety
Radiofrequency energy devices (RFED)
Mechanism of action
Efficacy
Safety
Ultrasound
Mechanism of action
Efficacy
Safety
Low-level laser therapy (LLLT)
Mechanism of action
Efficacy
Safety
Discussion
References
Education and teaching in plastic surgery
37
Education and teaching in plastic surgery
Introduction
Medical education theory
Adult learning theory
Bloom’s taxonomy and Miller’s pyramid
Dreyfus model
The evolution of plastic surgery education
The birth of a new specialty: plastic and reconstructive surgery
Present-day training model for plastic and re-constructive surgery residents in the US
Standardizing graduate medical education outcomes
Milestones
Entrustable professional activities
Competency-based graduate medical education
The future of plastic surgery education
Simulation in plastic surgery
Conclusion
References
Global plastic surgery
38
Global plastic surgery
Introduction
The global plastic surgery landscape
The role of the plastic surgeon in global surgery
Burns
Clefts and other congenital anomalies
Trauma
Oncologic reconstruction
Teaching
Advocacy
Research
Mentorship
Suggested guidelines for participation in global plastic surgery
Phase 1 – Engagement: why, where, and with whom?
Phase 2 – Logistics: what and how?
Phase 3 – Assessment and outcomes
Ethical considerations
Conclusion
References
Gender-affirming surgery
39
Gender-affirming surgery
Introduction
General preoperative evaluation
Hormones
Hair removal
Chest and breast gender-affirming surgery
Mastectomy
Preoperative evaluation and decision-making
Techniques
Double incision mastectomy and free nipple graft (DIFNG) (Fischer grade 2a-4)
Circumareolar/periareolar (Fischer grade 1 and 2A)
Postoperative management and outcomes
Breast augmentation
Preoperative and technical considerations
Postoperative management and outcomes
Genital gender-affirming surgery
Phalloplasty and metoidioplasty
Preoperative evaluation
Metoidioplasty
Phalloplasty
Flap design
Donor sites
Modular variations of phalloplasty types
Single-stage vs. staged phalloplasty
Single-stage phalloplasty
Big Ben method
Metoidioplasty-first
Implants
Complications
Donor site management and complications
Vaginoplasty
Preoperative evaluation and decision-making
Techniques
Penile inversion vaginoplasty
Intestinal vaginoplasty
Postoperative management and outcomes
Facial gender affirmation surgery
Upper third
Middle third
Lower third and larynx
Complications and outcomes
Conclusions
References
Confidence is ClinicalKey
Confidence is ClinicalKey